Man Overboard! summary

The scene: exterior, daylight. A muscular, gray-haired man is hard at work on a cattle ranch in rural Montana. The camera zooms in to show him dragging a horse trailer through a scenic valley with his bare hands. Everything’s going fine until – oh no! One of the trailer’s wheels is stuck in a vast, inconvenient puddle of mud. Afternoon ranch plans? Ruined. How ever will he get it unstuck?

Okay, so if you watch the rest of this commercial or any like it, you’ll know that the solution has nothing to do with crazy engineering feats, pickup trucks with heavy chains, or the like. This is what you might call a “think harder, not smarter” situation because no amount of rustic activities will get that cart back on the road. Nope, the correct answer is … “Viagra,” or any other drug to treat erectile dysfunction.

But wait a minute. Viagra?! How? Where? Well, what we have here is a classic case of television ads using metaphors for middle-aged men who have trouble getting erections – without telling you anything about the actual underlying health problem. And there’s been no shortage of these types of loosely-veiled analogies since Viagra and Co.’s big debut in the 1990s. Think of that sporty father of two who can now toss a pigskin football through that tire swing again – all thanks to the miracle drug being sold on TV.

In 2008, Big Pharma spent over 300 million dollars advertising drugs to treat ED. That’s more than was spent on ads for meds to treat osteoporosis, heart disease, or autoimmune disorders. And yet, ED was – and still is – surrounded by a lot of unanswered questions. In fact, it’s becoming ever more common, despite 20-plus years of drugs like Viagra on the market. But its effectiveness hasn’t been decisively proven. One review of 14 randomized trials found that 78 percent of participants who took Viagra reported an improvement in erections – but so did 25 percent of those who took a placebo, perhaps thanks to their newfound self-confidence.

So what’s the primary cause of ED? Could it be low testosterone – the hormone most often associated with male libido? It’s gotta be low T, right?

Not so fast. Get this: according to data from the European Male Aging Study conducted over many years, most men who reported troubles getting it up actually had boringly normal-range testosterone levels. So ED appears to be more of a physiological problem than a hormonal one. It’s true that testosterone usually reaches its highest levels in your late twenties, and then drops between 1 and 2 percent each year after that. It also rises and falls throughout the day – it’s highest around 8:00 a.m. and around 30 percent lower around 8:00 p.m. In terms of actual testosterone levels, there can be a lot of variation among different individuals, and this normal range changes according to age. So one person might have twice as much testosterone as another, but both could still have similar sex drives.

Since most people with ED don’t actually have low testosterone, it turns out that testosterone treatments in older men don’t usually make much of a difference, if any. That’s what a medical literature review conducted by the Institute of Medicine found in 2004. This prompted a later trial by the National Institutes of Health and the National Institute on Aging. They found that, for men with low T who averaged 72 years old, testosterone replacement therapy only moderately improved sexual function, improved anemia, mood, and walking speed a little, but didn’t change energy levels or cognitive function. It also increased the buildup of plaque – fats, cholesterol, and other substances – in the arteries, also known as atherosclerosis.

So if testosterone treatment isn’t the silver bullet for sex drive issues it had been hoped to be, does one even exist?

Erections actually start in the brain. The locus coeruleus area is in charge of stimulating sexual arousal with testosterone. As less testosterone becomes available with age, this area also becomes less responsive. But other factors can also diminish responsiveness to sexual stimuli, such as depression or alcohol. Some studies have found performance anxiety to play a big role as well. Nerve damage from diabetes, tobacco smoking, and high blood pressure, or hypertension, also make it more difficult to get an erection by damaging arteries in the penis that collect blood cells during an erection. ED turns out to be much more a total health problem than an isolated penis problem. So it makes sense to take a look at other health issues that become more common with age.