Young Americans are facing a stiff problem in the bedroom.
Across the country, a growing number of men in their sexual prime are struggling with erectile dysfunction — and leaning on prescription drugs to perform.
But that quick fix may not last forever. In fact, experts warn it could be setting the stage for a much bigger issue down the line.
“I’m starting to see it now — young guys who don’t respond to these medicines anymore,” Dr. Joel Hillelsohn, a board certified urologist at NYU Langone Ambulatory Care Chelsea, told The Post.
“These patients are going to be coming in more and more,” he predicted. “It’s not going to happen right away, it’s going to take five, six, seven years … but we’re probably going to see an epidemic of men who are failed cases.”
That could leave many with few options — and push some toward invasive, last-resort treatments just to stay in the game.
“I’ve had a couple of young male patients I’ve had to put penile implants in because they’ve exhausted everything else,” Hillelsohn said. But it doesn’t have to come to that.
For many men, Hillelsohn suspects there’s another path to a satisfying sex life — one that doesn’t start and end with a little blue pill alone.
Younger patients going soft
Erectile dysfunction was historically seen largely as an older man’s issue, affecting patients over 50 with underlying health problems.
“Typically, older gentlemen are going to be more likely to have erectile inconsistencies because of biological factors,” explained Rocky Tishma, a licensed marriage and family therapist and co-founder of Manhattan Sex Therapy.
Those factors can include age-related issues affecting blood flow to the penis, such as atherosclerosis, cardiovascular disease and hypertension. Other contributors include chronic illnesses like diabetes, medication side effects and hormonal changes like low testosterone.
“[The drug] works, but they always feel like their penis is broken … and it starts depressing them.”
But that profile is changing. Some studies suggest more than a quarter of men under 40 struggle to get or maintain an erection firm enough for satisfying sex.
“Recently, there have been a lot of younger men under 40 who are coming in after going through a primary care provider or a urologist and finding there’s nothing wrong physically,” Tishma said. “It ends up being a lot of stress, anxiety and psychological issues that are keeping them from being able to show up in their body how they want to.”
How the cycle begins
In Hillelsohn’s practice, a familiar pattern often plays out.
A young man experiences ED, sometimes after drinking or during a moment of nervousness. Then it happens again. They turn to Reddit or Google, where they find success stories and ads for drugs like Viagra or Cialis.
“That’s where the problem comes in,” Hillelsohn said. “[The drug] works, but they always feel like their penis is broken, so in the back of their head there’s this subconscious thought. ‘I have to take this med and there’s something wrong with me,” and it starts depressing them.”
Then other changes follow, like weaker morning erections and a drop in masturbation performance.
“Then some of them will start to lose their libido, because why would you want to go to a party if your pants are going to fall down?” Hillelsohn said.
What’s happening is something called the sexual tipping point.
“The concept is that everything is OK with erections, and then if something goes physically wrong, even a little bit, the scale gets pushed in the other direction, then you have all these mental factors that come up — my self doubt, my nervousness, my feelings of inadequacy — and it causes problems,” he explained.
The mind-body loop
Erections are driven by the parasympathetic nervous system, which releases nitric oxide when a man is aroused, allowing blood to flow into the penis.
But anxiety can disrupt that process. If even a small doubt creeps in — “is this going to work?” — the body releases adrenaline, the fight-or-flight hormone.
“It makes the penis a little less hard, and then they go into full on panic mode and they secrete more adrenaline,” Hillelsohn said.
That can trigger a “venous leak” effect, where blood flows into the penis but doesn’t stay there because adrenaline keeps the muscles tense.
The result is a vicious cycle: the more anxiety builds, the harder it becomes to maintain an erection.
“Viagra makes it worse, because now they’re thinking, ‘I have a problem. I have to take this pill,’” Hillelsohn said. “It doesn’t solve the underlying confidence issue, and it’s not fixing the leak, it’s just basically pouring more blood in there.”
Over time, he warned, the anxiety, stress and depression tied to sexual performance — and the venous leak they can trigger — may outweigh even the benefits of the drugs.
“I’m feeling I am going to see a lot more patients using these meds, not understanding the underlying problems, and over time the meds don’t work because their anxiety exceeds the possibility of the increased blood flow they can get from these medications. And then they’re out of luck,” Hillelsohn said.
What’s next? Penis injections
At that point, patients are left with no choice but stronger interventions, such as injectable drugs like Trimix.
“Then you’re injecting your penis every time you have sex, and you can get scarring,” Hillelsohn said.
Over time, frequent or improper use of drugs like Trimix can lead to complications such as Peyronie’s disease, which causes penile curvature, pain and worsening erectile issues.
One young patient, Hillelsohn said, started with Viagra, moved on to Trimix, and eventually developed scarring that led to a physical, or organic, venous leak.
“He’s going to be getting a penile implant at age 32 — and he’s not the first one I’ve had to do it for,” he said.
A different path forward
Hillelsohn says there’s still hope, particularly for younger patients whose issues stem more from psychological difficulties than physical problems — which he’ll check with tests.
“I want to prove to you that you’ve got a V6 in there, you’re just not turning the key,” Hillelsohn said.
From there, he prescribes a low daily dose of Cialis — not as a pre-sex medication, but as a reset.
“I don’t want you taking something right before, because then you’re already thinking about it,” Hillelsohn explained. “I want you every single day, taking a little pill so you’re not thinking about it, like a vitamin. I just want you to feel a little bit more full in the morning, more full in the afternoon, just constantly in your system.”
At the same time, he often encourages patients to seek sex therapy to address underlying anxiety and confidence issues.
The goal is gradual improvement: daily Cialis use, then tapering to every other day, then weekly, and eventually stopping altogether once anxiety fades and erections normalize.
“You’ve got to have successful sex to get rid of this pattern,” Hillelsohn said.
The most difficult patients to treat, Hillelsohn said, are those who have already tried ED drugs — often obtained through telehealth platforms — because it makes breaking the cycle more difficult.
“If you’ve already used these medications, it doesn’t give me that much to shock the system with,” he explained. “Then that’s it. We have very limited options.”
