The first step for an entrepreneur pitching investors is often to convince them that the problem they are trying to solve is real. That sounds simple, but it’s important: VCs are professional gamblers charged with identifying companies that have the highest likelihood of making them money. For a startup to do this, it typically needs to create a product or service that will be used by a large number of people. Seasoned VCs aren’t going to fund a solution to problem they don’t understand, much less aren’t convinced exists in the first place.
The problem Zachariah Reitano was trying to solve was simple: He wanted to make it easier for men suffering from erectile dysfunction to get a diagnosis and the appropriate medication, and to do it discreetly from home.
His startup, called Roman, launched last week. Users fill out a questionnaire that asks about things like blood pressure, symptoms of ED, medical history, and more. It’s then reviewed by a physician within two hours. If a patient is approved for medication, the prescription is filled and shipped to the user’s address in an unmarked box. There are still some kinks the company needs to work out–it doesn’t take insurance, and is currently only available in four states that it has agreements with doctors (New York, California, Florida, and Pennsylvania) — but the service is more convenient and, importantly, discreet than visiting a doctor’s office. (The startup Lemonaid Health has been filling online ED medication prescriptions for the past few years, but only offers pharmacy pick-up.)
Reitano didn’t have a hard time convincing investors that erectile dysfunction is a real issue. He arrived at each pitch armed with stats–ED affects an estimated 20% of men in their 20s, 30% of those in their 30s, 40% of those in their 40s, and so on–plus a personal call to action. At 17, Reitano experienced ED for the first time. (Twenty-six today, he’s experienced periodic bouts ever since.) After sharing his own story, multiple VCs opened up about their experiences with the condition. “It was great to see it resonate with other people,” he says.
The company quickly lined up high-profile backers, including General Catalyst, Alexis Ohanian’s Initialized Capital, and Casper CEO Philip Krim, raising $3.1 million in seed funding.
Like Reitano, Cindy Whitehead is a sexual health entrepreneur. If her name sounds familiar, that’s because she’s the creator of Addyi, the first FDA-approved drug to treat female sexual dysfunction. Originally developed as an antidepressant, Addyi works to boost sexual desire in women with chronically low libidos by targeting neurotransmitters in the brain.
Whitehead said she has received a flood of emails and letters from women thanking her for finding a medical solution to a problem they’d struggled with for years, sometimes decades. The reaction from investors, however, was frequently: Is this actually a problem? Whitehead recalls fielding numerous variations of the question, ‘but isn’t female Viagra just jewelry?’
Unlike with Roman, there wasn’t much of an overlap between Addyi’s potential customers and its potential investors. (Just 7% of venture capitalists at the top 100 firms are women. Whitehead recounts presenting to a primarily male audience at JPMorgan’s Healthcare conference, and watching the room descend into giggles at the mere mention of a woman’s sex drive.) Women’s health startups often struggle to secure funding for precisely this reason reason: investors, who are overwhelmingly male, don’t understand the products on a personal level.
But venture capital’s gender gap is only part of the problem. Low libido is a less established condition than erectile dysfunction, a discrepancy that mirrors broader trends in health, where men’s symptoms are generally better understood than women’s. In medical research, as in venture capital, the default is still male.
Until 1993, women weren’t included in trials for new drugs. “The thought was women might get pregnant during a study, and that could be harmful to the fetus,” says Dr. Janine Clayton, associate director for women’s health research at the National Institutes of Health (NIH). Even after the FDA lifted the ban, most studies continued to use male participants. This bias ran further down the pipeline: Historically researchers have used male animals in preclinical trials to avoid having to control for estrus cycles in female animals.
Researchers are beginning to unpack what this means in turns of diagnosis and treatments, in part because agencies like the NIH have taken explicit measures to fix the gender bias in preclinical studies. Until fairly recently, a heart attack was delineated by intense chest pain. We now know that sex plays a substantial role in how a cardiovascular arrest manifests and presents itself, however: women are more likely to experience subtler symptoms, including fatigue, shortness of breath, and nausea.”We’ve unwittingly developed tests that are biased to detect the disease in men,” says Clayton. There are indications that sex plays a role in the expression of a variety of other conditions, including depression, autism, and diabetes.
While welcome, new sex-specific insights will take time to emerge and be validated. As it stands today, much of our medical knowledge is based on data gleaned from male cells. In sexual health as in overall health, we have far more information on how drugs affect men than women.
Combine the gender bias baked into medical research with the gender bias baked into venture capital, and it’s not difficult to see why women’s health companies often struggle to raise funding. What’s more, the companies that do succeed have an outsized burden of justifying that a market for their product does, in fact, exist.
Take Addyi, which eventually raised tens of millions from unnamed private investors. After winning FDA approval in 2015, some analysts predicted the drug would make billions. Instead, it was a flop: released two years ago, sales have been anemic. So does that mean demand doesn’t exist? That’s a hard question to answer, as there are multiple extenuating circumstances to consider: the drug comes with serious side effects, questions have been raised about its effectiveness, and, perhaps most damningly, Valeant, the pharmaceutical company which purchased the drug the day after it was approved by the FDA, doubled the price to $800 a month and scrapped its marketing budget and sales force. (We’ll soon see if the drug can flourish under better management. This week, Valeant announced it selling Addyi back to its former owners after buying it two years ago for $1 billion).
While the above doesn’t necessarily disprove there’s a demand for libido-boosting drugs–perhaps a better designed or marketed drug would succeed where Addyi has, to date, largely failed–it doesn’t prove it, either.
When you consider Roman in this context, the company was two steps ahead right out of the gate. Not only is the problem it’s trying to solve “real”–backed by clinical research and a variety of popular medical options–but many of the VCs tasked with making funding decisions know the problem exists because they’ve experienced personally.
This competitive advantage shouldn’t detract from the company’s mission which, according to Roman cofounder Saman Rahmanian, is to dispel the “sense of stoicism that we think society encourages in men when it comes to health problems.”
“ED is one of the most uncomfortable things men face,” he continues, and shame associated with the condition often stop men from seeking treatment. Such avoidance is potentially dangerous, as ED is often an indication of a larger health problem.
Along with making it easier for men to consult with physicians, Roman is hoping to wash away some of this stigma associated with the condition. There’s clearly work to do on this front, even within the startup’s own walls. When I ask Rahmanian and cofounder Rob Schutz whether they’ve ever experienced ED, Rahmanian says no (later, he reconsiders and says he could have probably benefitted from medication when he and his wife were trying to conceive). Schutz says he has, but it was “a long time ago with a new partner.” (On a call, Alexis Ohanian, an investor in Roman, tells me he has never experienced ED–without me having to ask.)
Reitano hopes his own disclosure will encourage other men to take action, both by seeking out medical help and opening up to their partners. Telling his girlfriend he had ED ultimately strengthened his relationship, he says.
Whitehead wanted Addyi to facilitate similar conversations, but from the woman’s perspective. In her experience, the ability to talk about chronically low sexual desire in medical terms can be “a huge relief,” in part because it means blame takes a backseat.
Such conversations are going to be harder to have, at least for the foreseeable future. Men suffering from erectile dysfunction have a range of medical options at their disposal. Women suffering from chronically low libido have Addyi–a controversial, incredibly expensive drug.
As with most issues worth discussing, the reasons behind this gap in treatment options are interconnected, complex, and often ambiguous. But it’s hard to argue that gender doesn’t play a role. The first step in developing an innovative solution to a problem is recognizing that the problem exists. For sexual dysfunction in women, as with the ways so many diseases and drugs affect women specifically, we’re only now moving past square one.
Laura Entis is a freelance writer and editor based in Brooklyn. She has written and edited for publications including Fortune, Entrepreneur, Racked and The Guardian.