Operation Pangea is Interpol’s global crackdown on the $4.4 billion trade in illegal pharmaceuticals. The operation, launched in 2008, has led to thousands of arrests, the shuttering of “criminal websites,” and the seizure of more than 100 million units of counterfeit and illicit medication. The seized drugs include antidepressants, hormones, and various kinds of stimulants. Over the operation’s existence, however, there has been one standout: fake erectile dysfunction pills.
Interpol often coordinates a “week of action” in collaboration with national authorities around the world. Of all the products seized in 2022’s week, “counterfeit or unauthorized erectile dysfunction medicines comprised roughly 40 percent.” 2023’s week included operations in eighty-nine countries, and Interpol found that such medications “continue to be the most seized medicine globally, accounting for 22 percent of seizures during the operation.”
In Canada, the percentage has been significantly higher. During Operation Pangea’s 2023 week of action, Health Canada stopped 1,028 packages from entering the country and seized twenty-nine packages at border crossings, containing unregulated or potentially fake health products. Of all the packages seized that week, 72 percent contained sexual enhancement medications.
Canada has participated in Operation Pangea since its inception, but it also carries out inspections, seizures, and arrests on its own. For years, Health Canada has maintained an online database tracking the unauthorized sexual enhancement products seized from retail locations across the country. Between June and December last year, it updated the database with 341 new entries—a snapshot of what has been confiscated. Among these was a product called VIP Go Rhino Gold 69K from a sex shop in Quebec City, Quebec; Alien 2 Power Platinum 11000 from an “intimacy and intrigue” boutique in Moncton, New Brunswick; Stiff Rox Gold from a convenience store in Pickering, Ontario; Pink Pussycat from an adult store in Lethbridge, Alberta; and ResErection! from an adult entertainment store in Langford, British Columbia.
Each product promises to enhance sexual performance, and each one, according to Health Canada, is a black-market drug posing serious health risks.
Erectile dysfunction—or ED—has been a documented concern for millennia. Texts from ancient India describe urogenital issues and male sexual health problems in detail; pharaonic Egyptians depicted impotence in art; and there are several mentions of impotence and ED in the Bible. Treatments ranged from the legitimate—ancient Egyptians used lotus flowers containing apomorphine, a compound the Food and Drug Administration (FDA) later recommended for ED in 2000—to the potentially dangerous, with ancient Romans and Greeks consuming animal genitalia. It wasn’t until the nineteenth century that testosterone was found to play a role in male sexual health.
Near the end of the twentieth century, the first health agency–approved pill specifically marketed to treat ED appeared on the market. In 1998, the US pharmaceutical giant Pfizer released Viagra—initially developed as a treatment for hypertension and accidentally found to cause erections—revolutionizing access to sexual health treatments. The company hired former US presidential candidate Bob Dole as its TV pitchman and bought print ads with the tag line “Let the dance begin.” Later advertising, recognizing that stigma and embarrassment kept many from seeking help, featured an image of a happy couple with the line “I’m proud of him because he asked about VIAGRA.”
In 2003, a rival—Cialis—from Eli Lilly and Company hit the market. It contained tadalafil, instead of Viagra’s sildenafil, as the active chemical. Other PDE5 inhibitors, as they’re known, which relax the smooth muscles of blood vessels, have since followed, with Viagra holding 57.3 percent of the global market in 2024. And the industry is booming: its value is predicted to double from $3.27 billion (US) in 2023 to $7.74 billion (US) by 2033, with North America accounting for the vast majority of sales, according to a report by Brainy Insights.
By 2025, an estimated 322 million people worldwide, or around one in every twenty-five, will experience ED. This increase is linked to an aging population, more sedentary lifestyles, and a rise in chronic conditions like obesity and hypertension. According to Trustin Domes, a urologist and associate professor of surgery at the University of Saskatchewan, the rates of erectile dysfunction roughly correspond with age: 40 percent of men in their forties, 50 percent in their fifties, 60 percent in their sixties.
Legitimate medications like Viagra and Cialis require a prescription, but several barriers can stand in the way, including cost, access to a health care provider (22 percent of Canadians lack a regular family doctor, according to a recent OurCare report), and the stigma associated with seeking treatment. A recent study about the prevalence of ED in the US, based on data collected from a 2021 survey, noted “lack of need to see a provider” as the most common reason for not accessing care. In other words, ED alone was not seen as a significant enough reason to see a doctor.
To address these barriers, online health services have surged in recent years, allowing people to obtain medication without leaving home. Consultations and prescriptions are handled via online chat, phone, or video, with drugs discreetly delivered to their doors. Companies like Essential, Maple, and Felix prioritize ED treatment, promoting convenience as a key selling point—promising patients they can “get connected in minutes” or “skip awkward conversations with your doctor or pharmacist.”
Alongside these new telehealth services is a warren of questionable online pharmacies—companies claiming to fill the gaps by offering access to “convenient and affordable” medications via a simple form. One online pharmacy outlet called CanDrug—listed as a “licensed community pharmacy” by the College of Pharmacists of British Columbia—appears to be the root company for around a dozen different websites: Canada Pharmacy Online, which has the same mailing address in Surrey, BC, as Canada Pharmacy World, and which has a nearly identical website to both Canadian Pharmacy King and Big Mountain Drugs. All of these sites state the same Surrey address. Another, Canada Drugs Direct, notes on its website that “sale of [its] products are governed by the laws of the Province of Manitoba” but lists no physical address and only ships within the US.
Their homepages prominently feature banners advertising ED medication, offering Viagra and Cialis for around $30 to $50 per pill as well as lower-cost generic alternatives. But regulatory bodies have issued warnings. “While purchasing prescription drugs online may seem convenient and cheap, it may expose consumers to serious health risks,” notes the National Association of Pharmacy Regulatory Authorities, representing authorities in each province and territory. NAPRA recommends inputting the domain of an online pharmacy into a database maintained by the association’s counterpart in the US, the National Association of Boards of Pharmacy, to confirm whether it’s “safe to use.” CanDrug, Canada Pharmacy Online, Canadian Pharmacy King, Big Mountain Drugs, Canada Drugs Direct, and Canadian Pharmacy World are all on the NABP’s “Not Recommended List.”
“Some websites are legitimate online pharmacies, while others may be operating illegally,” Health Canada warns, noting pills purchased from these outlets can be dangerous or unauthorized and that they use marketing tactics that “often rely on a consumer’s shyness and fear as a way to push their products.” Some websites even mention, in fine print, that “packaging may be slightly different to that available in stores” and “shape, size and colour of the medication may also be different.” For Domes, another risk with using direct-to-consumer online pharmacies is that by skipping medical assessments, patients potentially overlook underlying health conditions. A long-term relationship with a doctor can help “rule out secondary or underlying causes of sexual dysfunction and not just treat it with a pill,” says Domes.
And while some online clinics may sell legitimate meds like Viagra or Cialis, there’s no guarantee that they aren’t coming from abroad or are counterfeit. For Domes, the issue is uncertainty. “You don’t know what you’re getting,” he says. “And what you get today may be different than what you get tomorrow.”
To fill the growing demand, an ED black market has thrived. A landmark 2017 study in Translational Andrology and Urology attributes its rapid growth to “the low risk of prosecution, potentially high financial reward, and ease of distribution via Internet pharmacies.”
In part, it’s a business built on counterfeit brand-name ED medications, packaged in blister packs with legitimate-looking labels. But it also includes a spectrum of so-called health products with colourful names and alarming promises. One capsule, 3800 Hard Rock, seized by Health Canada earlier this year from a Hamilton, Ontario, convenience store boasted effects that “lasts 7 days.”
These products, according to the study, are “perhaps even more dangerous” than counterfeit Viagra or Cialis. “Unsuspecting patients often seek alternative treatments of ED due to embarrassment and lower cost, but also because of the perception that ‘all natural’ products are somehow safer than synthetic medications,” Health Canada notes. This subjects consumers to “the same risks with even less warning.”
Both kinds of black-market pills, says Domes, are “rampant” in Canada. They’re sourced from online retailers, brick-and-mortar stores, or travellers bringing them from abroad. Amazon has repeatedly sold sexual supplements containing unregulated amounts of tadalafil. In 2022, it was forced to recall two products—the Red Pill That Never Sleeps and Hard Dawn Rise and Shine—as they contained undisclosed amounts of tadalafil. The following year, the FDA sent a letter to Amazon threatening legal action over the continued sale of such supplements.
While some take ED drugs for medical reasons, research suggests a growing number of men use them recreationally. One study describes the trend as “a sexual enhancement aid among men without a medical indication,” while another report points to “mounting evidence” of this trend. Domes concurs. Some people, he says, don’t have any form of sexual dysfunction, “but what they want is super function.” He says that this particular market is typically younger, unlikely to receive a prescription, and therefore they seek illicit pills instead.
The health risks are real. These pills “may be missing active ingredients, contain the wrong ingredients or dangerous additives such as prescription drugs, be expired, mislabeled, subject to recalls, or counterfeit versions of authorized product,” a Health Canada representative wrote in an email statement to The Walrus. They could be made in unregulated laboratories and contain contaminants; some illicit ED pills have been found to contain gypsum, amphetamine (the active ingredient in Adderall), and commercial grade paint.
Several of the so-called alternative remedies seized by Health Canada actually contain significantly more sildenafil or tadalafil than authorized prescription medications such as Viagra or Cialis. During a series of store raids in BC in 2021, Health Canada found capsules being sold that contained more than three times the legal dose of tadalafil. Consumers could experience heart attack, stroke, high or low blood pressure, and abnormal heartbeat. These pills can also alter the efficacy of other medications. “It’s a bit like playing Russian roulette,” Domes says. Yet demand—and the black market—remains.
Illicit products are intercepted in the mail system or confiscated at borders. According to numbers provided by Health Canada to The Walrus, between September 2021 and September 2023, Canada Border Services Agency seized 2,976 health products at border crossings—of which 820 were suspected counterfeit ED drugs coming from around the world: 71 percent from China and the rest from more than a dozen other international sources, including Ukraine, India, Thailand, Mexico, the US, and the UK. Meanwhile, around the country, Health Canada continues to seize products in adult entertainment shops, health and wellness outlets, convenience stores, gas stations, and supermarkets.
In some cases, these seizures have led to legal action. The owner of one adult product chain in Alberta was charged with the repeated—despite warnings—sale of unauthorized male sexual enhancement drugs containing sildenafil or tadalafil. He was later fined $30,000 and given a year-long probation order that prohibited him from selling, importing, or distributing any kind of health product, legal or otherwise. One company that was caught selling illegal sexual enhancement products is facing charges under the Food and Drugs Act.
Beyond law enforcement efforts, Domes sees health care access and education as key to addressing risks. When he sees patients for blood work or blood pressure checks, it’s a chance to talk about sexual health. And if ED is what brings them in, “it’s a chance for us to do some health promotion and prevention”—and perhaps steer them away from the black market.
