New Yorkers love to complain, and the subway is one of our favorite things to complain about. The delays! The crowding! Over 5 million people ride the subway every day, and the ads we stare at also become a part of our collective conversation (Dr. Zizmor!). A few months ago, riding the subway with my nose in a book, I was pulled back into the real world by an ad for a company I hadn’t heard of before: Roman. Roman was selling “The erectile dysfunction drugs you definitely don’t need, but your ‘friend’ was asking about.”
My stomach sank. I’m the “friend” who was asking about Viagra. I was the butt of this joke.
A month or two before that subway ride, I’d talked to my therapist about erectile dysfunction, two words so unattractive together that they’re universally shortened to ED. I’d just started antidepressants in the wake of an awful breakup, and those drugs — or that breakup or my work stress or my financial stress or my family pressures or the 45th president or NYC rent prices — made me anxious about sex. Anxiety made me nervous, and nerves made me not get hard.
I’d started dating a boy, and that boy was a bottom, and I liked him. Dating someone I liked made my anxiety, and thus my ED, worse. My therapist asked if I could talk to the boy about it. I could, but not well, and a week or two later, our relationship fizzled for that reason or a thousand others.
So I talked to my doctor about erectile dysfunction. I sat in a room with him, nervous to mention it. We decided that I could try Viagra and see what I thought.
Many of us gays grew up hating so much about our bodies — or being afraid of what might happen to them.
The subway ad for Roman reminded me that I shouldn’t want to talk about any of this. Roman and another brand, Hims, have received millions of dollars in venture capital funding ($3 million and $7 million, respectively). These brands deliver men’s lifestyle drugs via diagnosis over the web or on the phone. With Roman, the pills are then shipped “discretely” to customers’ doors. The services are inexpensive, and both brands attempt to be comparable to a primary care visit and traditional insurance, but they are — for me — more expensive than what I pay going through my doctor.
Yes, I am an upper-middle-class white gay cliché. I take Lexapro and Propecia and Viagra and Truvada, the HIV prevention drug. But I’m also from a working-class Irish Catholic background where men don’t admit to physical weaknesses, illness included. Instead, we tough it out.
Shame and silence about sexual performance undergird and power masculinity. These same forces — shame and silence — are so common to the experience of being young and queer.
Many of us gays grew up hating so much about our bodies — or being afraid of what might happen to them. I got beat up for being fem in a small town. I grew up terrified that kissing a boy would mean a life where AIDS was inevitable. So it makes sense to me that we, as a community, want so badly to have control over our own flesh.
If bodies are our currency and pleasure our capital, investing in keeping these bodies as desirable as possible only makes sense. Once we remake our bodies and find our pleasure, we finally have something to lose.
I’ve grown to mostly love myself, and I definitely have something to lose. But if I share the things I’m most afraid of, they become less daunting to face. The practice of talking about my ED to as many people as possible, including my doctor, is a part of how these things lose their power to frighten me. It was hard to talk to my doctor about ED. It’s harder still to write about it, and damn near impossible when I imagine people reading it (oh god, my exes!). Sometimes it’s important, even critical, to do the big, hard thing.
Masculinity seems to me directly tied to sexual performance. James, a friend of mine, whom I’ve talked to about ED meds before, told me that “My sexual prowess was always a big part of my identity in a way I didn’t even realize up until the point it was threatened. It was something I was proud of.”
By sexual prowess, I think he meant his ability to top, and to top anytime, probably because that’s what most men wanted from him.
According to Hims and Roman, both, men purchase drugs like Viagra and Propecia online and have for years, often illegally. “So much of this medicine is being purchased off label and off brand. We hear all the time guys are going online to try to import generics from India and Canada,” explained Hims founder and CEO Andrew Dudum in a recent phone interview. “The situation is kind of a scary one.”
Are the convenience and subtlety of e-medicine worth the trade-offs?
Zachariah Reitano — a cofounder of Roman who is public about having used ED drugs himself — told me that they’re filling gaps that exist because men don’t like to talk about their health. “Only 18% to 25% of people who experience ED receive treatment for it,” he explained in the offices of Roman here in Manhattan, a well-lit open space full of computer workstations. “And the most recent study showed that about 75% of PCPs [primary care providers] don’t ask about your sexual health.” All this silence is deadly: Men aren’t comfortable talking to health care providers about our aging and our sometimes imperfect bodies. We’re less likely to go to the doctor.
Proponents of e-medicine argue that it’s cheaper — for men and women both — and provides better services to the patients than your grandparents’ general practitioner. Who wouldn’t rather tap an app and not fidget in a sterile-feeling waiting room crawling in everyone else’s germs? And Dudum told me that they can provide the kinds of follow-ups by text or email that are simply impossible for typical doctor’s offices.
But are the convenience and subtlety of e-medicine worth the trade-offs?
I’d been through all this a decade before, in 2007, when I first started taking other drugs offered by Hims: drugs for male pattern baldness.
I’d noticed some hair loss already in college. College is when my grandfather — my mom’s dad — started losing his hair. He was my lesson in toxic masculinity. When he was older, he broke bones falling because he refused to use his walker. That thing wasn’t manly. He didn’t need it.
I loved my hair. I was just figuring out I was gay, and like most gay youngsters, I was afraid of aging out of my own beauty before I’d ever sucked a single dick.
In 2007, I’d just started a PhD program. I worked on protein biochemistry, so I could look up the drugs I was thinking about taking and understand the clinical and biochemical research before talking to my doctor.
By understanding how drugs work at the molecular level, you can advocate for yourself to your doctor on more equal footing, which might be especially important for women, people of color, queer people, trans people, and people in more than one of these categories. This makes us better able to make choices outside of the (ridiculous) drug ads we see on TV and Big Pharma’s ethically dubious advertising directly to our doctors, and the ads we see on the subway, too.
Propecia is an inhibitor of the enzyme 5-alpha reductase, which produces a testosterone derivative called dihydrotestosterone (DHT). DHT drives hair loss. Inhibit 5-alpha reductase, get less DHT, lose less hair, and maybe even gain some back. Studies show it’s remarkably effective, producing some hair regrowth in 66% of men after two years and preventing loss in more than 80%. Side effects are usually minimal, but among the more common side effects is ED. I decided it was worth this small risk.
Not surprisingly, when men do go to the doctor, we are taken more seriously and get better care.
I read up on the meds I wanted to take. In so doing, I was also figuring out ways to think about — and to talk about — the drugs, and why I was taking them, without attaching as much shame and stigma. It made me focus on the drugs and my body, and less on how taking the pills would seem to others. And having gone through all this with Propecia, a decade later, I could trust my doctor to ask about my anxiety and about ED. But of course, not everyone has the benefit of a PhD program to learn about drug-binding kinetics and how and where to find clinical study data. Part of my work in the queer community is to increase scientific literacy so more of us can learn how to advocate for ourselves.
And the laws around drugs and how they’re sold matter here too. Hims and Roman can exist because Viagra and Propecia recently went off patent, and so low-cost generic substitutions are available. My insurance covers my Propecia (rather, the generic finasteride). My latest three-month refill of finasteride cost a grand total of $5. Reitano from Roman told me that insurance doesn’t often cover ED meds, although for people like me whose ED is a side effect of other meds, or for those with PTSD, there is often an exception made.
How we define lifestyle drugs is slippery and difficult. Is hair loss a disease? Or is culture sick for thinking that baldness isn’t sexy? I’m afraid of answering this question honestly because if I do, I might have to stop taking this drug that has, in my own mind, kept me beautiful and fuckable well into my thirties. Though I hope that I’d still be fuckable even bald, because I would still have a body worthy of pleasure and I would still be a kind, empathetic, caring person who wants his lovers to feel good too.
Dudum from Hims pushed back on any of these medications being classified as “lifestyle drugs.” “We want to offer the best medicine,” he said. “Only true, prescribed, scientifically backed medicine, so that we can look at a man and say, ‘hey, the top five issues that you’re concerned about, we have curated access to physicians to look at your case in particular.’”
To the average man, then, it doesn’t matter if medicine is “lifestyle” or not. Reitano more or less agrees: “We’re here to enjoy our lives, and so I think quality of life is incredibly important for people.”
And maybe they have a point. My mom, a nurse practitioner, sees tons of patients of all ages in her office to talk about acne, and she’s told me for years how much happier people are when they realize that treatment can make an astounding difference in how they look, and so how they feel.
Whether or not it’s a “lifestyle drug,” studies have shown that Viagra leads to positive outcomes in terms of overall health. Mental health is health. Lexapro saved my life, and Viagra improved it.
I just wish we could be advocating for everyone, but especially women, to have this level of agency over their own bodies. Not surprisingly, when men do go to the doctor, we are taken more seriously and get better care. The fact that Viagra has been covered by some insurance companies that don’t cover birth control was rightly lampooned in the media. Abortion and birth control, essential elements of health care, should be as cheap and easy to access as Propecia, if not more so.
Hims and Roman have been advertising directly to the queer and black communities, with Snoop Dogg on YouTube and ads in my Grindr app. Queer and black communities have a reasonable distrust of the medical infrastructure that has literally tortured them. This isn’t history; micro- and macro-aggressions and bias still abound.
Is an app the answer? According to Dudum, “Men are really, really excited to start opening up in this mechanism of telemedicine where there’s no bias. We’ve been doing a lot of studies on how in-person consultation versus telemedicine consultation changes from a bias standpoint, whether it’s gender bias, sexual orientation bias. [In telemedicine,] you don’t have any type of bias.”
But even the studies provided by Hims’ PR show that, while telemedicine does better than traditional medicine in many cases, it doesn’t seem to be a silver bullet.
And Hims and Roman are only selling medicine to men. Their entire conversation centers around who men are and what men do. I worry that trans men and nonbinary trans people are entirely erased in these conversations, and guess what, trans people worry about hair loss too.
There are still things telemedicine absolutely can’t do — like check your prostate. How do they do that? According to the Mayo Clinic, “your doctor performs the test by inserting a gloved, lubricated finger into your rectum to feel the prostate for bumps or other abnormalities.” And fear of invasive exams is one of the reasons men say they avoid going to the doctor.
Despite the rise of telemedicine, public health professionals are still working toward getting men, people of color, and queer people into their doctors’ offices. This is one reason for New York’s aggressive push for free and easily accessible PrEP (Truvada — a prophylactic pill for HIV prevention).
It was hard, but not impossible, for me to sit in front of a doctor and say that I’d had unprotected sex the night before, and that I wanted PEP (postexposure HIV treatment). It was hard, but not impossible, to sit in front of my doctor and ask for Propecia and Viagra.
Each conversation chips away at the shame and the stigma, healing in its small way my heteronormative past.
Hard things are lessons, and practice. The lesson is this: If I can ask my doctor once about the things that bring me shame, I can ask him again. If I can ask my doctor about Viagra, I might even be able to talk to my partners about what’s going on. Each conversation chips away at the shame and the stigma, healing in its small way my heteronormative past, and I’ve come to believe that small ways are the only way we heal. Each conversation is practice for the hard moments that might be still to come — the diseases we have yet to meet and hopefully survive. Talking to my doctor, in person, made it possible to talk to James, and talking to James taught me that I wasn’t alone in my issue, my fear, my body. It was a gift for me and James both.
“I’m still lucky,” James tells me, but his voice goes high at the end before trailing off, and I know he’s not quite telling the truth. He’s grateful for his access to care, but the pill hasn’t fixed his anxiety, the way he feels better or worse about himself depending on the pleasures his body can give and receive. This feels so 2018: “Be skinny! Be covered in hair but only in the right places! Have clear skin all the time all your life! And if you aren’t or don’t, here is an app that will fix it!”
Apps and pills won’t cure cultural ills. The shame — the silence — that brings us to Roman or Hims, that’s what’s killing us. Why would we expect Roman or Hims to seriously want to decrease that shame and silence? They profit from it.
Roman writes on its website that “As society has proclaimed, men like fixing things.” I seriously hate proclamations about what “men” like to do.
But people of all genders — let’s fix things.
Let’s talk about sexism and its effects on all people. Let’s talk about how to love ourselves and others in this tough world. Consumerism, of products and people, can feel ubiquitous to the extent where we almost no longer see it. Health should be exempt; we need information and literacy, not marketing with penis-shaped cacti.
Let’s talk about how our government is making insurance more difficult to get. Let’s talk about drug prices in the US versus the rest of the world, and how the cozy relationship between Big Pharma and our government subsidizes that industry and keeps our collective health care costs high.
Let’s talk about all that. Let’s admit to the failing of our bodies out loud. Let’s shout it from the rooftops. Let us tell our friends and families and — oh my goodness — our lovers too! I take Propecia. And Viagra. I take Lexapro for chronic anxiety. I take Truvada as HIV prevention.
Having better health care, and a better relationship with our health care provides, shouldn’t be a privilege. Better, cheaper health care will give us all, all of us, the ability to manage our bodies, our mental health, and yes, our pleasure. How we look, thanks to Propecia. How we feel, thanks to Viagra, Lexapro. How we fuck, thanks to Truvada. Some of this is costly, but it is well worth the cost. Through these pills, we have a modicum of control over what we do with this one body, the only body we’re given. ●