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Official websites use. Share sensitive information only on official, secure websites. Mounting evidence indicates that erectile dysfunction medications EDMs have become increasingly used as a sexual enhancement aid among men without a medical indication. Recreational EDM use has been associated with increased sexual risk behaviors, an increased risk for STIs, including incident HIV infection, and high rates of concomitant illicit drug use. The aim of the present study was to investigate the characteristics and associated risk factors for recreational EDM use among young, healthy, undergraduate men. A cross-sectional sample of 1, men were recruited from undergraduate institutions within the Unites States between January and May The survey assessed patterns of EDM use, as well as demographic, substance use, and sexual behavior characteristics. Four percent of participants had recreationally used an EDM at some point in their lives, with 1. The majority of recreational EDM users reported mixing EDMs with illicit drugs and particularly during risky sexual behaviors. Overall, recreational use of EDMs was associated with sexual risk behaviors and substance abuse; however, a relatively small proportion of undergraduates reported using EDMs. Results also suggest that a sizable portion of recreational EDM users are heterosexual men, and that use does not solely occur within the environments of venues that cater to men having sex with men. There are currently three oral medications approved by the Food and Drug Administration FDA for the treatment of erectile dysfunction ED : sildenafil Viagra , tadalafil Cialis , and vardenafil Levitra. These erectile dysfunction medications EDMs are well tolerated and effective for treating ED of various etiologies Goldstein et al. Although these EDMs have been FDA approved to treat ED, mounting evidence indicates that these drugs have become increasingly used as a sexual enhancement aid among men without a medical indication. This phenomenon has raised concern particularly with respect to its association with increased sexual risk behavior. In addition, studies report frequent use of illicit drugs taken concomitantly with EDMs such as, but not limited to, methamphetamines, methylenedioxymethamphetamine MDMA, ecstasy , cocaine, alkyl nitrites poppers , and ketamine Chu et al. Concordant use of EDMs and illicit drugs poses several serious health concerns. Use of nitrates and EDMs simultaneously is contraindicated as it can cause severe hypotension, cardiac complications, and even death Ishikura et al. Furthermore, concurrent use of illicit drugs and EDMs may potentiate high-risk sexual behavior by increasing social disinhibition while simultaneously enhancing sexual performance e. Prior studies have begun to provide much needed data on recreational EDM use; however, they are not without their limitations. Second, the preponderance of studies has used relatively small convenience samples recruited from specific geographic locales, which has limited the generalizability of these findings. Third, studies have not established an event-specific association between EDM use and increased sexual risk behavior. Although there appears to be a relationship between these behaviors, more data are needed with respect to the time of EDM use and the specific type s of sexual behavior. Finally, a paucity of studies has investigated EDM use in an undergraduate population. The present investigation was designed to provide the first national study conducted in the Unites States examining EDM use in heterosexual, bisexual, and gay undergraduate men. Our first aim was to assess the rates of recreational use of sildenafil, tadalafil, and vardenafil and explore descriptive characteristics related to their use, such as frequency and length of use, motivations for use, source s of acquisition, and concomitant illicit drug use. Second, we aimed to investigate associated risk factors for recreational EDM use, including demographic characteristics, as well as sexual behavior and substance abuse characteristics. Individuals participating in this study were part of a cross-sectional convenience sample and were recruited from colleges and universities within the Unites States between January and May Overall, 3, individuals activated the online survey. Of these men, exited the survey without answering any items; 2, participated in the survey to various extents, to which 1, questionnaires were complete enough for statistical analysis. Participants resided in 43 states, as well as the District of Columbia, and represented distinct undergraduate institutions. The sample had a mean age of Characteristics of the participant sample are presented in Table 1. Participant characteristics: national cross-sectional sample of undergraduate men within the United States, — Represented students who did not identify with a formal academic year, the majority of which were students who either recently graduated or were in a post-baccalaureate program. Engaging in sexual intercourse within the past 4 weeks. Data were missing for three participants. Men were assessed as to whether they had ever used an oral EDM and, if yes, the types used sildenafil, tadalafil, and vardenafil and purpose of use e. Participants indicated whether they had ever combined an EDM with recreational drugs. Because many of the items on the IIEF are related to sexual intercourse within the past 4 weeks, only sexually active individuals completed this questionnaire. Participants were asked whether they had ever engaged in sexual intercourse and, if yes, the age in years at which participants had experienced their first intercourse, and whether participants were currently sexually active engaging in intercourse within the past 4 weeks. In order to evaluate sexual risk behaviors, participants completed items that assessed their number of sexual partners during the past 4 weeks, 6 months, and 1 year. Response options were 0—1, 2—5, and more than 5. Finally, participants reported whether they have ever contracted an STI during their lifetime. Those reporting yes were asked to indicate which type s and whether they had ever engaged in unprotected oral-genital sex or unprotected intercourse while showing symptoms of an STI. Participants were asked to report the number of times they had used particular illicit substances within the past year. They also reported on their frequency of alcohol use and patterns of use frequency of inebriation , as well as tobacco use number of cigarettes smoked daily. Male participants aged 18 and older were recruited via online classified advertisements as well as through online social networking sites e. All participants were required to read an online consent form before gaining access to the anonymous survey. The survey did not use cookies and did not collect user IP addresses. After completion of the min survey, each participant was debriefed and given a random identification number that served as a confirmation that he had completed the survey. This cutoff value has been demonstrated to have a sensitivity of 0. Additional analyses using alternative cut points for illicit drug use and alcohol use did not change the results. A Pearson product moment correlation coefficient was used to quantify the relation between age and erectile functioning. All analyses were performed using SPSS statistical software version The total sample of men had a mean IIEF erectile function score of Characteristics of erectile dysfunction medication use: national cross-sectional sample of undergraduate men within the United States, — The following results pertain to only those participants reporting recreational EDM use and these are also shown in Table 2. Among current recreational EDM users, the mean frequencies of use are as follows: 1. Of men reporting concomitant use, mean frequencies were as follows: 1. Men who recreationally used EDMs reported high rates of unprotected intercourse with individuals of serodiscordant or unknown HIV status. No association was found between EDM use and ethnicity, household income, relationship status, total number of drinks consumed during the prior month, and tobacco consumption. Association between demographic and substance use characteristics and recreational EDM use in a national cross-sectional sample of undergraduate men within the United States, — Multivariate model adjusted for age, sexual orientation, number of drug types used within the past year, number of one-night stands lifetime , presence of a sexually transmitted disease, and ever engaging in unprotected vaginal intercourse with someone of serodiscordant or unknown HIV status. Recreational EDM use was also found to be significantly associated with a number of sexual behavior characteristics Table 4. Association between sexual behavior characteristics and recreational EDM use in a national cross-sectional sample of undergraduate men within the United States, — Number of drug use occasions retained significance as an independent risk factor for recreational EDM use, and the association was strengthened as the number of drug use occasions increased. Compared with men who reported no drug use during the prior year, adjusted odds ratios for EDM use were 2. Number of drug types used within the past year and likelihood of EDM use also displayed a dose response, with those using two to four drug types and those using greater than four drug types exhibiting adjusted odds ratios of 4. Men using only one drug type were more likely to use an EDM; however, this association did not reach statistical significance. Multivariate analyses examining the association between recreational EDM use and sexual behavior characteristics are shown in Table 4. Men reporting an intermediate number of sex partners 11—50 reported a marginally significantly higher adjusted odds ratio compared to the reference group. The current study examined patterns of and associated risk factors for recreational EDM use in a large geographically diverse sample of undergraduate men in the United States. Frequency and breadth of substance use were both independently associated with recreational EDM use. These findings were similar to other studies examining patterns of recreational drug and EDM use in young men Chu et al. Another point of concern is that the majority of men who mixed EDMs with recreational substances did so during sexual activity. EDMs in combination with illicit drugs may permit men in altered states to engage in unsafe sexual behaviors, creating concern for STI and HIV transmission, as well as unwanted pregnancy. Studies examining rates of unprotected anal sex with a partner of unknown or differing HIV serostatus in men have reported similar results. These studies found an increase in unprotected anal sex with a partner of unknown or serodiscordant HIV status among sildenafil users, with recreational users between two and six times as likely to engage in this risk behavior Chu et al. However, it is important to note that, after we controlled for demographic, substance use, and sexual behavior covariates, these sexual risk taking behaviors were not independently associated with EDM use. In our study, men reporting a gay or bisexual sexual identity were approximately 3 to 3. This is in line with a study that recruited men seeking public STI services in San Francisco, whereby gay and bisexual men were four times as likely to report recreational EDM use. Additionally, older age was associated with recreational EDM use. This is in accord with other studies reporting increasing EDM rates with increasing age, even in samples of young men with relatively small age ranges Benotsch et al. Recreational EDM users were also more sexually unrestricted compared to nonusers. Specifically, men who recreationally use EDMs reported significantly higher numbers of lifetime sexual partners as well as higher numbers of one-night stands. In fact, men reporting more than 50 sex and more than 5 one-night were approximately 10 and 7 times as likely to recreationally use EDMs, respectively. An important point to note is that the presence of clinically significant self-reported erectile difficulties was independently associated with EDM use. The 2. Santtila et al. This is an important consideration considering that the largest increase in sildenafil use among commercially insured adults in the U. That being said, one cannot rule out the possibility that frequent substance use which can independently cause erectile difficulties may be etiologically responsible for the increased rate of self-reported ED. Unfortunately, this cannot be ascertained by our data, given the cross-sectional nature of our study design, as well as the fact that we did not specifically assess this relationship. Several limitations of this study warrant mention. As a result of the cross-sectional nature of this study, we acknowledge the need to exercise caution in making direct casual inferences of any kind. The association between recreational EDM use and sexual risk behaviors warrants further investigation, in the form of prospective studies in multiple populations, in order to establish temporality of EDM use preceding sexual risk behaviors, as well as a potential causal link between recreational EDM use and increased risk of psychogenic ED. Additionally, the sample of under graduate men may not generalize to the population of young men in the United States for several reasons. Second, it is likely that this population of college men has an unintentional over-sampling of individuals who are relatively wealthy and educated. Third, our data indicate that African-American individuals were under sampled while Asian-Americans were over-represented U. Bureau of the Census, Fourth, considering that this survey was sexual in nature, biases among participants participating in sexuality research should also be considered e. Another limitation is with respect to the method of data collection. Participants provided their responses via self-report on the Internet, thereby making it impossible to verify the validity of their data. However, collecting data online may also serve as an advantage in that it involves greater anonymity which may facilitate participants in disclosing intimate information. A final limitation was that there was no way to ascertain whether EDMs used by participants were in fact genuine pharmacologically active , and therefore it is impossible to discount the possibility that some EDMs were inert, particularly those acquired from online pharmacies. In conclusion, data from this national cross-sectional sample of undergraduates in the Unites States indicated that a relatively small portion of men recreationally used EDMs. Among those that did report use, EDMs were associated with sexual risk behaviors and substance abuse. Results also suggest that a sizable portion of recreational EDM users were heterosexual men, and that use does not solely occur within the environments of venues that cater to MSM. The NCCAM had no further role in study design; in the collection, analysis, and interpretation of data; in preparation and the writing of the report; or in the decision to submit the paper for publication. The authors thank Alison Marks for help with online data management and data acquisition. As a library, NLM provides access to scientific literature. Arch Sex Behav. Published in final edited form as: Arch Sex Behav. Find articles by Christopher B Harte. Find articles by Cindy M Meston. Issue date Jun. PMC Copyright notice. The publisher's version of this article is available at Arch Sex Behav. Open in a new tab. STI Sexually transmitted infection. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Other a. Geographic residence b. Sexually active c. Erectile dysfunction d. Counteract drugs that decrease erectile capacity. Among recreational EDM users who concomitantly use illicit drugs. Drug types used b. Drug use occasions b. Days drunk past week c. Lifetime b. One-night stands lifetime c. Erectile functioning d. Risky sexual behavior e.

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