Blog 2: A Typology of Human Enhancement Drugs (HEDs): The Case of Sexual Enhancers

By Rosa Koenraadt

Whether it’s a herb, powder, pill or cream, there is no shortage of advertisements promising quick and easy weight loss or muscle growth without diet or exercise. According to many of these ads you can lose 25 pounds in two weeks simply by taking slimming pills, or develop a six-pack by taking the right dietary supplements. And this is only the start; there are vitamins, minerals and herbs that are said to prevent you from getting the flu, hair growth drugs that supposedly restore your voluminous hair, and drugs that give you an amazing tan without having to rely on the sun. Whether much of this is true remains doubtful, but the fact is that human enhancement drugs (HEDs) are all around us. A wide selection of products to look young, to become slim or to feel fit are legally available in local pharmacies, drugstores and/or supermarkets. However, HEDs are not only available through the traditional supply chain but a wide assortment of lifestyle drugs and products are illegally offered as well via under-the-counter in shops, through online marketplaces and pharmacies, or from your local dealer on the street.

HEDs are defined as products being taken for reasons to improve the quality of life and/or to enhance human attributes or abilities. However, what kind of products, consumers and markets can we specifically identify? It is clear that human enhancement drugs are in high demand. Reasons why pills, products and creams are consumed on such a wide scale are diverse. Students who buy cognitive enhancers (e.g., Ritalin) online to improve study results belong to a different category of consumers than men who purchase sexual enhancers (e.g., Viagra) in the pharmacy with a doctor’s prescription. In order to gain a better understanding of the reasons they are consumed, to identify stages between healthy and problematic consumption, and to analyze the different legal, illegal and semi-legal HED markets, it is important to disentangle the variety of HEDs that are currently widely available. It is therefore valuable to adopt a typology of different types of legal, illegal and semi-legal HEDs, to understand the differences between markets, motives, quality, side effects and consumers.

As described in the previous HED blog there are six general types of HEDs: (1) muscle drugs (e.g., steroids); (2) weight-loss drugs (e.g., ephedrine); (3) image enhancers (e.g., skin-lightening products); (4) sexual enhancers (e.g., Viagra); (5) cognitive enhancers (e.g. Adderall); and (6) mood and social behavior enhancers (e.g., Diazepam). Here, I will explore sexual enhancers with particular attention to the variety of products available and the most avid consumers of these products. What follows is based in part on my current research on the trade in illicit lifestyle medicines in the Netherlands. For my research project I have conducted interviews with suppliers, traders and consumers of illicit medicines in the Netherlands and China, analyzed websites and court cases of suppliers and traders, and conducted a survey among 592 users that bought medicines online.

Medical and recreational consumers

Sexual enhancers (SEs) are drugs that are being taken in order to stimulate the erectile function and/or have the purpose as an aphrodisiac to improve arousal and sexual behavior. Some of the SEs, such as Viagra and Cialis, are used as a medical treatment for men with erectile dysfunction. In March 1998, the American Food and Drugs Administration first approved Viagra as a new medicine for the treatment of erectile dysfunction. Within one year of release the drug was available in 77 countries worldwide and one and a half years later, the medicine was being prescribed to 15.6 million men in the U.S. alone. In 2003, Cialis was approved and in 2007 Levitra followed with the active ingredients Tadalafil and Vardenafil respectively.

Although the initial purpose of these products was as a medicine for the prescribed treatment for erectile dysfunction, these substances became popular to a much wider audience. Therefore, with regards to consumption a distinction can be drawn between medical/clinical consumers on the one hand, and recreational consumers on the other. Medical consumers of SEs are diagnosed with an erectile dysfunction and have a medical/clinical reason for using SEs. Medical consumers are able to buy SEs in the pharmacy with a doctor’s prescription.

Recreational users however, do not have a clinical diagnosis for using SEs, but are taking the SEs for lifestyle purposes. For instance, recreational consumers may use SEs to prolong sex, to be able to perform sexually after a night out of drinking, out of sheer curiosity or for extra confidence while engaging in sexual activity. As one male respondent (53) claimed: “I use [SEs] for almost ten years already. Usually when I visit these [fetish] parties. When you are taking drugs like XTC, you can try to have sex but it will not work. A friend of mine gave me a Kamagra pill to try. Sometimes the combination feels heavy, but it is important not to take too much at the same time.” Another user stated (28): “I had a date with someone I met on a holiday. We met in a nice hotel and I thought well, let’s take some of this to enjoy the night even more.”

The boundaries between recreational and medical consumers may become blurred, as both medical and recreational consumers may use SEs for lifestyle purposes to some extent. However, we can draw a distinction between patients who – for whatever reason – could potentially purchase SEs with a doctor’s prescription and the recreational consumers who take the SEs for extra fun, curiosity or extra confidence on a first date, without the possibility to obtain the medication through the official pharmacy.

Licit and illicit SEs

The distinction between medical and recreational consumers is an important step that brings another division in the market. We have the regulated market where SEs are manufactured, distributed and sold through the regulated supply chain. This may include the natural food supplements in the supermarket or the medicines available through the (online) pharmacy. Alternatively, we can distinguish the illicit market where unregulated or unlicensed supplements and medicines are being sold. This may include the sale of counterfeit medicines or unlicensed generics. In between the two – and illustrative for HEDs – we can also identify a semi-legal market, or a market at the boundary between legality and illegality. This includes mainly adulterated food supplements with experimental chemical substances, for example herbs that claim to be fully natural but contain the active substance Sildenafil.

Generally speaking, recreational consumers are able to legally purchase products that do not require a doctor’s prescription such as licit natural food supplements and over-the-counter (OTC) SEs. As these products do not always have the desired effect, recreational users may move to purchase actual medicines in the illicit market. Medical consumers are able to purchase licit SEs both in the supermarket, drugstore and medicines with a doctor’s prescription. But this group of consumers may often for financial reasons, convenience or shame to visit a doctor, purchase SEs in the illicit market as well (see figure 1).

Nieuwe figuur Rosa.jpg

Figure 1: typology of licit and illicit consumption of sexual enhancers

Similar to the blurring boundaries between consumers, the differences between legal and illegal SEs is not always clear. However, it is important to acknowledge the overall distinction between products sold in the regulated supply chain, often through pharmacies, some online pharmacies, drugstores, or supermarkets and those products sold on unregulated or illicit markets, such as fake online pharmacies or vending sites, street dealers or under the counter in shops.

The balance between the licit and illicit market is difficult to estimate, as the scale of an illicit markets is inherently difficult to measure. Naturally, in illicit markets traders, vendors and users are trying to hide from enforcement agencies. While surveys and interviews may provide estimates as a first measure, they are often unreliable. For example, for the respondents it is often difficult to determine whether the product is legal or not. In 2014, an interesting study was conducted in an attempt to estimate the scale of the market through the use of sewage. As the SE Viagra contains the effective ingredient Sildenafil, the National Institute for Public Health and the Environment (RIVM) in the Netherlands compared the amount of Sildenafil in the sewage in four different cities in the Netherlands with the official sales of Viagra through pharmacies. In turns out that at least 60% of the measured Sildenafil in sewage cannot be traced back to the sale through official pharmacies.

A further distinction

The licit market for SEs may be divided among prescription drugs, over-the-counter products and herbal food supplements. For example, in the Netherlands SEs containing Sildenafil can only be purchased with a doctor’s prescription. However, ‘natural’ SEs may be purchased in the drugstore or pharmacy and do not require a doctor’s prescription. Importantly, regulations on which medicines need to be bought with a prescription differ from country to country and often change over-time.

Finally, an analysis conducted by the Dutch RIVM on seized SEs offers further distinction within the illicit market. Specifically, the RIVM identified four different groups.

  1. A first class consists of counterfeit medicines, such as the fake Viagra, Cialis or Levitra pills. Brand names are used, however the drugs are not originating from the claimed company or are mislabeled at a later stage. In the report of the RIVM these counterfeit SE’s accounted for 17% of the analyzed products.
  2. The largest proportion of illicit SE is illicit generics. These are pharmaceuticals legally produced in one country but not accepted in another. The best known example is Kamagra, originating in India. Based on the analyses from 2012, 69% of all analyzed SEs belonged to that group.
  3. The third group is the illicit food supplements, which are very much related to novel psychoactive substances (NPSs). The food supplements contain analogues (or: ‘designer drugs’), which are substances with the same pharmacological effect as the original substance (such as Sildenafil) but they may differ in side effects and potency. Often the full effects are even unknown. Besides, the packages usually claim a ‘natural food supplement’ on the label but in reality they contain active substances. One problem with this is that consumers may assume to take supplements while in fact they are using a pharmaceutical.
  4. A fourth group has been labeled illicit other. This group consists of SEs containing other chemical substances (such as illicit drugs or other medicines) or SEs in other forms. For example, instant coffee powder for men containing Sildenafil.

Another category that might be added to this typology is the unlicensed drugs which are the SEs that are manufactured outside the legitimate supply chain, without the use of an existing brand name.

Two examples of category (1) counterfeit SEs, and (4) ‘illicit other’ containing Sildenafil:

Afbeelding 1Afbeeldong 2

Photos taken by the author at Dutch customs, Amsterdam 2012

Conclusion

It is clear that, as with many human enhancement drugs, within the domain of SEs there is a great deal of overlap between the types of consumers, types of products and markets. For all the HEDs applies that there may be a distinction between recreational and medicinal consumers, or products containing legal or illegal substances, yet there are various grey zones with semi-legal substances or reasons for consumption that lie at the boundary of a medical and lifestyle need. Motives for consumption, popularity of products and the health risks may vary over time and culture as well. Nevertheless, in order to unravel the complexities of the HED markets, a good place to start is to discuss and elaborate on the different types of users, to distinguish between various reasons for HED consumption, and to identify different types of legal, semi-legal and illegal human enhancement drugs.

For any suggestions, comments and/or questions, please contact Rosa Koenraadt through email, Twitter or through the HED team.

More information on this topic can be found here:

  • Koenraadt, R.M. & de Haan, M. (forthcoming). De aankoop van geneesmiddelen via internet. Een onderzoek naar het koopgedrag, de motieven, risicoperceptie en informatiebehoefte van online kopers van geneesmiddelen. Utrecht: Willem Pompe Instituut voor Strafrechtswetenschappen.
  • Koenraadt, R.M. (2015). Cultural criminology and the Internet: Challenges for online criminological research. In: De Jong, F. (ed.), Overarching views of Crime and Deviancy; Rethinking the Legacy of the Utrecht School. The Hague: Eleven International Publishers, p. 547-564.
  • Koenraadt, R.M. (2014). Blauwe handel. Een criminologisch kwalitatief onderzoek naar illegale erectiemiddelen in Nederland. Tijdschrift voor Seksuologie, 39, 8-14.
  • Koenraadt, R.M. (2012). Blue pills on the black market. CIROC Newsletter, 10, 4-5.

The author would like to thank Katinka van de Ven and Kyle Mulrooney for their time and valuable comments.

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