This article was originally published in Maclean's Magazine on July 19, 2004
Female Sexual Dysfunction: Epidemic or Manufactured Problem?
THERE'S BEEN PROMISING NEWS in the science of female sexuality of late. Very favourable indeed, particularly if you're a rat. A few weeks ago, James Pfaus, a Concordia University researcher working on behalf of Palatin Technologies, a New Jersey-based pharmaceutical company, announced his discovery that, when injected with a synthetic hormone called PT-141, female rodents become overcome with lust - hopping, darting to and fro, and sending all sorts of come-hither vibes to their male companions. Pending further studies - and U.S. Food and Drug Administration approval - Palatin plans to market the drug as a libido-booster for women, to be administered nasally. "Right now, there's nothing in the arsenal for women to treat a desire disorder," Pfaus said. "I think this is the first salvo." To be sure, a nasal spray is not a conventional foreplay tool. But if Palatin can prove that one squirt of PT-141 will get women revved up (in spite of, as is the case for many, fatigue, job stress, perhaps even a loveless marriage), you can bet they'll be stocking up on this stuff.
PT-141 is only one of a slew of drugs, ointments, gels and patches currently being developed to treat a newly minted medical condition: female sexual dysfunction. It's a loose designation encompassing all manner of women's sexual woes. As a concept, FSD is still in its infancy; it began receiving widespread attention after a closed-session conference in Boston in 1998 (heavily sponsored by the pharmaceutical industry).
Symptoms of FSD are so many and varried that, as U.S. social critic Barbara Ehrenreich has put it, "the criteria for not being dysfunctional seem extremely high." A woman may qualify as dysfunctional if she has chronic, or even occasional, trouble becoming aroused; if she has difficulty achieving orgasm - or if she's never had one; if she experiences any sort of pain during intercourse; or, if she's the type who'd just rather eat chocolate and do her nails. Based on this umbrella definition, the medical and pharmaceutical communities are claiming women of all ages are suffering from FSD in near epidemic proportions. They say a whopping 43 per cent are harbouring some kind of sexual dysfunction (compared to 31 per cent of men). Is it time to panic?
Of course it's no coincidence that this trend is emerging hot on the heels of erectile dysfunction madness, which generated billions in treatment revenues. Over 23 million men have been prescribed Viagra since it was approved in 1998. The advent of this drug - and subsequent copy-cat drugs including Cialis and Levitra - ignited a minor cultural revolution, which got both men and women enumerating their sexual goals to their doctors more freely than ever before. But now that men of any age are able to perform like high-school quarterbacks, many women are eager for an effective counterpart drug. It's our turn, they're telling their physicians, to be measured, poked, prodded and outfitted with a magical thrill pill. We want to sing My Way in the shower at the top of our lungs, for a change.
The study of female sexual dysfunction has become the fastest-growing discipline in sexual medicine. It's anticipated that up to US$3 billion will be spent over the next decade in the race to manufacture mojo-inducing products for women. Currently, there are no pharmaceuticals approved for the treatment of FSD. (Some doctors have prescribed off-label items believed to help increase libido, including testosterone creams and even Viagra, but for the majority of women, they've proven ineffective.) Still, drug companies, from Eli Lilly and Co. to Proctor & Gamble Inc., are hard at work, trying to crack the code with chemical lotions, potions and ingestibles.
In Search of the Mojo Pill
Outside of the labs, though, a war is raging over the medicalization of women's sexuality and the hazy notion of what's "normal." Perhaps because women, unlike men, are not equipped with built-in arousal meters, the question of women's sexual function - what's standard and what's appropriate - has long been a source of curiosity and discomfort in the medical community. For centuries it's been seen as a problem to be solved, although most of the solutions to date have been less than helpful.
In the late 1800s, doctors estimated that as many as 75 per cent of women were suffering from "hysteria," a nervous condition thought to be the consequence of insufficient sexual intercourse or lack of sexual gratification. Having established a large, lucrative market, doctors made small fortunes treating "hysterical" patients with everything from horseback riding sessions to primitive vibrators. In the 1950s, long after vibrators were discarded from physicians' kits, gynecologists joined psychiatrists in embracing Sigmund Freud's notion of "frigidity." The cure for this condition - characterized by a woman's inability to become aroused and achieve orgasm during sex - was a combination of tranquilizers and psychoanalysis.
Now, to some critics within the sexual health community, female sexual dysfunction is just another dubious term, much like hysteria or frigidity. They're concerned that, by trying to define what sexual dysfunction is in women, doctors and pharmaceutical companies have implicitly created a blueprint for normality. Any deviation from that is then considered a sickness. Which begs some questions. What gives scientists - not traditionally considered experts in the fields of love and intimacy - the right to establish norms? Is female sexuality even conducive to such formatting? And even if it is, do we really want to be looking to doctors and pharmacists to put us in the mood?
Yes, say American celebrity sisters Laura Berman, a sex therapist, and Dr. Jennifer Berman, a urologist. Youthful and telegenic, the Berman sisters are at the forefront of the movement promoting the study of FSD. They host TV and radio shows, are frequent guests on Oprah, and are the co-authors of For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life. Earlier this year, Laura Berman opened the Berman Center, a state-of-the-art, one-stop mojo-shop where patients with FSD can practise yoga, learn targeted pelvic excercise, get sex-friendly nutritional tips, and have their genital blood flow monitored and their hormone levels tested, all in one "spa-like" medical clinic. It's the first of its kind in North America.
Laura Berman says it's about time the medical community began treating women's sexual dissatisfaction as a serious issue - a courtesy that has been extended to men for some time. Historically, she says, women's sexual complaints have been dismissed by doctors as being "all in their head." Women with deeper concerns were brushed off and told to have a drink or a hot bath. The fact that the dialogue about FSD is even taking place, she says, is a sign that the sexual revolution was not waged in vain. "Women today are more aware when something's missing," she says, "and they're not necessarily prepared to take the loss of their sexuality sitting down."
Originally, Berman was a practitioner of talk therapy. But she started to incorporate physiological medicine into her practice in 1998 when she began to find that some of her patients were making no progress, regardless of the amount of time they devoted to dissecting personal "issues." With some patients, she says, "We had mined for every emotional, relationship or historical issue that could have been contributing to the problem, and had come up empty. Eventually, it was clear that it was her body that wasn't working the way it should."
Sure, the pharmaceutical industry has an obvious financial stake in researching FSD treatments, Berman acknowledges. But she also points out that drug companies are contributing to a growing understanding of women's sexual physiology, something never before examined in depth - and something that could improve the lives of many. "I don't think any particular medication is necessarily going to be a fix-all panacea," she says. "But I think the research being done looks very promising."
Quickly - Define 'Normal'
Even critics of the FSD label concede there are many things that could cause hormonal imbalances, blood-flow problems and other conditions that may impede a woman's sexual well-being, including the onset of menopause, high cholesterol, heart disease and diabetes, to name a few. Prescription drugs such as oral contraceptives and antidepressants, as well as excessive smoking, alcohol or drug use, can also factor in.
Skeptics, however, argue that the medical and pharmaceutical communities are exaggerating the problem, playing up the importance of physiology and lumping together vastly different conditions to make FSD seem more pervasive than it is. "It would be great if the largest cause of women's sexual dysfunction was physiology," says Robin Milhausen, co-host of the Life Network's Sex, Toys & Chocolate and a former clinical researcher at the Bloomington, Ind.-based Kinsey Institute. "We could all pop a pill and instantly become more easily aroused and orgasmic, but no study so far has found that. Women are way too complicated."
In fact, in a comparative Kinsey study that the Collingwood, Ont.-born Milhausen conducted on sexual arousal in men and women, she found that, overwhelmingly, the most important issues that influence women's sexual well-being are self-image, relationships, psychological health, social connectedness and cultural expectations - all of them inextricably intertwined. Physiology plays into it for a very small percentage, she says, "but unless the other variables are going well, it doesn't really matter about physiology. There are hundreds of things that can shut off a woman's arousal." Maybe she's lost her job, or her house is messy, her kids are nagging or her partner's breath is appalling. It could just be because of a bad hair day.
This is more or less the conclusion that Pfizer, the maker of Viagra, seems to have reached several months ago. The company had been testing its drug on women, but then officially pulled out of the FSD race, conceding that Viagra worked only with men. (In fact, most women felt more improvement with the placebo than the drug. At least it didn't cause headaches and hot flushes.) Female sexual disorders, Pfizer's researchers concluded, are "far more complex than male erectile dysfunction."
'Sexuality Is Elastic'
Perhaps the most vocal opponent of FSD research is Dr. Leonore Tiefer, a sexologist and clinical professor of psychiatry at the New York University School of Medicine. Tiefer spearheaded FSD-Alert, a group of activists, to challenge what she calls the myths propagated by the pharmaceutical industry, and to encourage a more humanistic, drug-free approach to sex therapy for all. (The group's second major conference is scheduled to be held in Montreal next summer.)
One of Tiefer's biggest concerns about the way sexual dysfunction is publicized and the way drugs are marketed is that it creates a culture of anxiety. "A lot of young women have completely internalized the notion of FSD," she says. "I see patients all the time who wonder what's the matter with them. Their libido is just not there all the time and there must be something wrong."
What it comes down to, she says, is fending off a manufactured concept of normality: that there is a right way to conduct your sex life and an ideal number of encounters or orgasms or fantasies that one should have per week. "Sexuality is elastic, so there is no natural standard," she says. "You could have sex twice a day your whole life, or never your whole life, and it wouldn't matter healthwise." So it may take more than a pill or a nasal spray to solve the riddle of women's libidos. But the race is on, and the chemical compounds are flowing. Which may not be such a bad thing - especially if you're a rat.
Knowledge is Power: A short history of what we didn't know about female sexuality (and were afraid to ask)
4th Century - Some Romans believe that women can lower their sexual desire and prevent pregnancies by ingesting pigeon droppings mixed with oil and wine, or by rubbing their loins with the blood of ticks taken from a wild black bull.
1500s - Italian doctor Mateo Renaldo Columbus is the first to scientifically recognize the female orgasm. He notices a hill-like appendage, naming it the clitoris, after the Greek word for "little hill." His research lands him in prison.
1800s - Medical authorities identify an epidemic of hysteria among Western women. The medical treatment? Clitoral massage. British doctor Joseph Mortimer Granville later patents the first electro-mechanical vibrator, allowing doctors to treat six female patients within an hour instead of one.
1918 - Sears Roebuck offers a vibrator in its catalogue, describing it as an "aid that every woman appreciates."
1962 - U.S writer and future Cosmopolitan editor Helen Gurley Brown creates a stir with her best-selling book Sex and the Single Girl, discussing the advantages of unmarried life - including a healthy sex life. Feminists laud her as a pioneer.
1970s - Micro-dissection techniques improve medical knowledge about how nerves and blood vessels work in the penis. Researchers don't bother doing similar studies on the clitoris.
1987 - American Psychiatric Association removes "nymphomania" from its manual of mental disorders; it also drops the male equivalent, "Don Juanism." The APA later continues to back away from sexual dysfunction diagnoses, excising "sexual addiction" in 1994.
1998 - Helen O'Connell, an Australian doctor, discovers that the clitoris is twice as large as previously believed, and that many terms used for female genital parts are - inaccurately - based on the male anatomy.
Maclean's July 19, 2004