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2018-08-04 06:21:46 Commentary

As an andrologist — a doctor specializing in male diseases — I frequently encounter people who ask me about erectile dysfunction. One recent patient had no quibbles about coming straight to the point. A somewhat bossy man in his 40s or 50s, he strode straight into my consultation room and demanded a prescription for ten boxes of Viagra. When I asked why he needed so much, he replied straight-faced that he was planning a party with a few friends and needed pills to “liven things up a bit.”

Fortunately, most of the time, I’m spared mental images of my middle-aged patients’ more orgiastic maneuvers. Another recent patient was a much more typical case: He ostensibly came to see me about a routine semen analysis, and after the initial consultation — right as he was walking out — he turned back and asked what we in the medical profession call a “doorknob question.” These are often the true reasons for the patients’ visit, and in andrology, it’s often when men confess that all’s not well in the bedroom.

Naturally, I’m not in the business of prescribing industrial amounts of Viagra to just any guy who asks for it. As with everything in medicine, I have to follow certain procedures before putting patients on a course of treatment. In the latter patient’s case, I used an internationally recognized questionnaire to evaluate the extent of the man’s erectile dysfunction and determined that it indeed required treatment. However, just as I was writing him a prescription, the man adopted a serious expression. “Doctor,” he said, “I’ve heard that Viagra has a number of side effects and is even addictive. Would it be possible to give me something else?”

To me, the contrasting attitudes of these two recent patients sum up China’s relationship with medications that treat sexual function — especially frontline medicines like Viagra and Cialis. Some men take them recreationally, even in excess; others regard them with suspicion and don’t dare touch them.

In Chinese, erectile dysfunction is colloquially called yangwei. It’s one of the language’s more visual euphemisms: Yang means “masculine energy,” and wei means “to wilt.” Although attitudes toward sex are becoming more open, it remains taboo to talk about sex in China. Society has historically viewed male sexual dysfunction as shameful, and even though media outlets and internet forums help to promote discussion about the topic, many patients remain ignorant or suspicious of existing medical treatments.

Even today many Chinese men still distrust Western medicine to such an extent that I have to convince them to reluctantly accept a prescription for Viagra.

As a result, many men with erectile dysfunction feel embarrassed or ashamed about it, and rarely confide in their loved ones or consult with doctors. Unfortunately, some even attempt to treat erectile dysfunction in unorthodox or medically unsound ways. Since the early 1990s, certain companies have boasted self-styled secret recipes that promise to increase male virility and sexual prowess. At the same time, so-called black clinics — underground medical establishments often staffed by unlicensed personnel — promise to cure impotence, premature ejaculation, and sexually transmitted diseases.

More and more Chinese people are gradually coming to understand that erectile dysfunction can have a deeply negative impact on sexual relationships, family harmony, and quality of life. As a result, there is increasing demand for effective and legitimate treatments, and the field of andrology has flourished. In 1995, the Chinese Medical Association established its Andrological Division. Since then, it has offered specialized help to a vast number of patients, often prescribing one of the most formidable weapons in andrologists’ arsenal — Viagra.

This year marks 20 years since sildenafil — the medication sold under the brand name Viagra — became available around the world. Before its arrival, treatment for erectile dysfunction verged on the inhumane. In most cases, men had two options: They either used a vacuum erection device, or penis pump, to draw blood into the penis and keep it there by constricting the base; or they injected vasoactive drugs directly into the erectile tissue. The former was uncomfortable and had variable results, while the latter was highly effective but caused scar tissue to form in the penis, eventually leading to permanent loss of erectile function.

Meanwhile in China, a number of bogus traditional remedies for male sexual dysfunction flourished. Men would consume tiger and deer penises to enhance virility, while others bought snake-oil health supplements promising to improve kidney function. (In traditional Chinese medicine, strong kidneys are considered key to male sexual health and fertility.)

So when Viagra and other PDE5-inhibitory drugs — those that work by blocking certain enzymes in the body — came onto the Chinese market in 2000, they were a revelation. Viagra is easy to consume, works for around 80 percent of men, and has few serious side effects. Indeed, the “little blue pill” has proven so effective in China that people have given it its own nickname — weige, or “mighty brother.”

Nonetheless, even today many Chinese men still distrust Western medicine to such an extent that I have to convince them to reluctantly accept a prescription for Viagra or similar drugs. Traditional medicine remains a highly profitable business in China, and many patients aren’t willing to trust foreign remedies — regardless of their proven success rates.

At the same time, the Chinese market for male sexual dysfunction drugs is becoming increasingly commercialized. In May 2014, Viagra’s Chinese patent expired, triggering a flood of domestically produced imitation drugs. The China Food and Drug Administration (CFDA) approved 16 such drugs for sale in the country — all of which have sildenafil as their key ingredient.

The CFDA says that sildenafil should only be available on prescription, but many imitation drugs can be bought over-the-counter in pharmacies.

Most Chinese companies selling Viagra-like drugs combine seductively low prices with high-intensity advertising. These techniques have not only made these companies profitable, but have also helped to raise public awareness of erectile dysfunction. But there is a dark side to their popularity, too. The CFDA says that sildenafil should only be available on prescription, but many imitation drugs can be bought over-the-counter in pharmacies. Such lax enforcement leads to some men severely distrusting sildenafil-based treatments, and others using them recklessly, like the abovementioned patient hungry for a party drug.

In May, the Chinese public reacted with skepticism and outrage to an announcement by the Hebei Changshan Biochemical Pharmaceutical Company. The announcement stated that a medication for erectile dysfunction produced by one of its subsidiaries had been approved for sale, adding that an estimated 140 million men live with erectile dysfunction in China, and if only 30 percent of them sought treatment for it, the domestic market for such drugs could be worth up to 10 billion yuan ($1.46 billion) a year. In the days following the announcement, Hebei Changshan’s shares skyrocketed.

Investors and stockholders alike accused Hebei Changshan of inflating statistics in an apparently successful bid to attract finance and boost company value. Many cited China’s National Bureau of Statistics, which placed the country’s male population at 708 million for 2016. If Hebei Changshan’s numbers are true, opponents argued, then that would mean that nearly 1 in 5 men live with erectile dysfunction.

But the truth is that erectile dysfunction might be even more common than that. A 2017 meta-analysis compiled by Chinese researchers summarized the findings of several epidemiological investigations with a combined total of more than 48,000 participants among all age groups, and concluded that just under 50 percent had experienced the symptoms of erectile dysfunction at some point in their lives. This high prevalence mirrors the results of the famous Massachusetts Male Aging Study from 1994, which reported a pooled prevalence of 52 percent among American men over 40 years old.

The number of potential erectile dysfunction patients in China has pharmaceutical companies gearing up for another marketing offensive. As more drugs come onto the market, as advertisers find more effective ways of selling them, and as more men accept Western-derived medical treatments, I predict that more and more Chinese men will buy drugs for sexual dysfunction over-the-counter.

Worryingly, we cannot yet trust all men to use this medicine safely. There are reasons why the CFDA demands that certain drugs are only available on prescription, and one of them is to ensure patient safety. Without a concerted effort to educate men about the potential dangers of such treatments, we risk putting them in danger.

Translator: Lewis Wright; editors: Zhang Bo and Matthew Walsh.

(Header image: An advertisement for Viagra is seen at a drug store in Shanghai, Nov. 19, 2012.Weng Lei/IC)