Hot startups like Hims and Roman are marketing Viagra to young men online, but their approach raises 2 big questions

Most people associate erectile dysfunction with the silver-haired men in Viagra commercials.

Yet Zachariah Reitano was just 17 years old when he experienced it for the first time. Confused and frustrated, he knew something was wrong.

He was right. It’s well-established among doctors that erectile dysfunction can be the first sign of a more troubling health problem, especially in younger men.

Later diagnosed with a heart condition, Reitano compares erectile dysfunction to “the check engine light in your car going off.”

“It’s a sign that something is wrong, but you don’t exactly know what,” he wrote in a blog post. Unfortunately, many men ignore that sign because of the embarrassment and stigma that surrounds the condition, he says, and doctors often don’t raise the subject during checkups.

Reitano’s experience led him to start the men’s health company Roman, which prescribes and delivers medications like Viagra and its lower-cost generic, called sildenafil. Roman is one of a slew of new companies like Hims and others shaking up the traditional model of healthcare by offering this kind of online service targeted specifically at erectile dysfunction.

These new companies paint erectile dysfunction as a problem among younger, not-yet-greying men, but one for which there is help.

That raises two key questions. How can these online companies care for patients who could have serious underlying health conditions like Reitano? And are these companies over-hyping how common erectile dysfunction is in younger men?

Read more: Trendy startup Hims wants to shake up men’s health by prescribing generic Viagra online and is nearing a $1 billion valuation. But a move to relax guidelines has raised concerns among some of its doctor partners.

Roman and its telemedicine peers, though, say they can direct patients to get appropriate care, even if it’s not through their own companies. They also say they’re combating the stigma associated with impotence by talking about the condition openly and making care accessible in a discrete, affordable way.

A ‘window of opportunity’

At its most basic, an erection happens because of blood flowing to the penis. Trouble getting an erection could mean that something is getting in the way.

Because that part of a man’s body contains very small blood vessels, erection problems could be the first sign of heart disease or other problems with blood circulation. Erectile dysfunction also has plenty of other potential causes, including common medications, psychological factors and health-related behaviors like drinking and not exercising.

Not every young man with erectile dysfunction is going to have an underlying heart problem, urologist Dr. Hossein Sadeghi-Nejad told Business Insider, “but certainly some of them do.” Sadeghi-Nejad serves as president of the Sexual Medicine Society of North America, which promotes high standards in treating human sexual dysfunction, and co-authored the American Urological Association’s erectile dysfunction guidelines.

The AUA guidelines recommend a physical exam, which can’t be done online.

“I think to lose that window of opportunity to address the bigger problem would be a pity,” Sadeghi-Nejad said.

Without an in-person exam, some physical causes of erectile dysfunction could be missed, he said, giving as an example the handful of times in a year when he’s had patients who turn out to have a tumor in their testicles.

Roman CEO Reitano knows from firsthand experience that a Viagra prescription won’t solve an underlying health problem. But Roman can help patients find out about the connection, including by strongly recommending that patients get in-person tests, and then walking them through the results and next steps for free, Reitano said.

When Roman began working in erectile dysfunction, it found that many of its members smoked, a risk factor for erectile dysfunction. So the company next expanded into products that help them quit, Reitano said, and now sells the prescription smoking cessation aid bupropion as well as nicotine gum.

“I come to this as a patient,” he told Business Insider. “We treat our patient for life.”

If Roman’s physicians can’t treat a patient, they refer him to nearby health centers and physicians, something that it has done for thousands of patients, Reitano said.

Read more: A startup aims to help the 18 million US men diagnosed with erectile dysfunction pay attention to their ‘check-engine light’

These online companies all patch patients through to doctors, but they have different approaches and styles.

Rival Hims’ website reads at first like an e-commerce experience, greeting potential patients with the different categories of medical products they can shop—hair, sex, skin, or vitals—and then glossy product images. After a patient adds Viagra or another prescription product to his online cart, he gets directed to a medical consult.

See also: We tried to buy generic Viagra online from Hims and failed — here’s how it went down

Online telemedicine services like Hims are a powerful opportunity to “find people who do have medical problems, and get them to doctors that can help them,” according to Dr. Peter Stahl, a Hims medical consultant and the director of male reproductive and sexual medicine at NewYork-Presbyterian Hospital/Columbia University Medical Center. As part of his role at Hims, Stahl came up with advice for Hims’ doctor partners that they can look at if they have questions.

According to those recommendations, one goal of care is to identify health conditions that can underlie erectile dysfunction, he said, which might include diabetes, testosterone deficiency, high cholesterol and vascular disease. Hims’ doctor partners “routinely” recommend patients see a specialist, rather than writing them a prescription, if they decide that is the best course of treatment, the company said in a statement.

Lemonaid Health is another telemedicine company offering erectile dysfunction medications. The start-up says it is more of an online doctor’s office, and aims to care for the patient as a whole. A patient who clicks on Lemonaid’s various medicines and treatments gets directed to set up a doctor consultation, which might include answering online questions or a live video interaction.

On a page about erectile dysfunction, the company points out that it can be the first sign of things like heart conditions, cardiovascular disease and diabetes, and says that it offers an optional lab test to look into those possibilities.

Lemonaid also offers a service to quit smoking with the smoking cessation aid Chantix or Zyban, and one to manage patients’ cholesterol, which might include a statin prescription. Both health problems are linked to erectile dysfunction.

“When we do turn away patients, we think of other opportunities to help,” Dr. Davis Liu, chief clinical officer of Lemonaid, told Business Insider. The company also plans to launch services for depression and anxiety, high blood pressure and diabetes this year.

40% under age 40

Viagra has been sold for about 20 years, and recently became available as an inexpensive generic drug. In its prime, the brand-name product — brought to market by Pfizer — brought in more than a billion dollars a year for the drug giant.

Back then, the type of older man frequently featured in Pfizer’s ads was a prime demographic, or roughly ages 40 and over, a 2006 article from the peer-reviewed medical journal PLOS Medicine found.

But new online startups offering erectile dysfunction medications have men under age 40 in their sights, and cite a popular statistic: that erectile dysfunction affects up to 40% of men by that age.

That statistic comes from one of the most important studies to measure the prevalence of erectile dysfunction, the “Massachusetts Male Aging Study,” which randomly selected men between ages 40 and 70 to participate.

As part of the study, researchers gave men a questionnaire to “characterize erectile potency.” They found that 52% of men reported some level of erectile dysfunction, ranging from minimal to moderate to complete impotence, and that age was strongly connected to the condition. Complete erectile dysfunction was more infrequent, according to the study, ranging from around 5% in the 40-year-old set to 15% by age 70.

The study found that at age 40, about 40% of men had some level of erectile dysfunction, but didn’t look at younger men.

Still, that figure isn’t a good estimate for the proportion of men who need erectile dysfunction drugs, urologist Sadeghi-Nejad told Business Insider. While up to 40% of men may have at some point experienced trouble getting or maintaining an erection by age 40, he draws a distinction between chronic erectile dysfunction and occasional experiences with it.

In other words, not every guy who has experienced erectile dysfunction is bothered enough by it to see a doctor, or to take a medication for it. Online companies offering easier access to generic Viagra and other erectile dysfunction medications could change that, he noted.

Erectile dysfunction research often excludes younger men, according to a 2017 study by Italian researchers. One exception was a large study published in 2004, which found that erectile dysfunction affected 8% of men in their 20s and 11% of men in their 30s.

Hims and Lemonaid told Business Insider that the 40% figure is accurate, citing its use in peer-reviewed medical journals and the evidence-based medical resource UpToDate. Roman’s Reitano said in a statement that the “vast majority” of the start-up’s members are older than age 40, with an average age of 46.

Hims has been dubbed the “millennial erectile dysfunction company” because its splashy advertising appears designed for men in their 20s and 30s, including through use of a color dubbed “millennial pink” and tongue-in-cheek eggplant emojis. The startup treats men starting at age 25 and going up to age 65.

Hims consultant Stahl calls promoting awareness of erectile dysfunction in this population an important step forward.

Young men are a large part of his in-person practice at Columbia, he said. The condition is less common in men in their 30s and 40s than in older men, but those who do have it are “excellent candidates for treatment,” he said.

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