I wrote this a couple of weeks ago as a course essay and, having heard the title, a few people asked to read it so I thought I’d put it up here.
On the tenth of February 1999, the Journal of the American Medical Association (JAMA) published an article titled, Sexual Dysfunction in the United States: Prevalence and Predictors, in which its authors, Edward O. Laumann, Anthony Paik, and Raymond C. Rosen stated that, based on a national probability sample of 1749 women, 43% of the adult female population aged between 18 and 59 suffered from female sexual dysfunction (FSD).
Two months later, the JAMA published a correction stating that two of the authors had failed to disclose their financial ties to drug companies – Laumann to Pfizer Inc and Rosen to Pfizer Inc, Merck & Co Inc, Eli Lilly Co, Bristol-Meyers Squibb & Co, Proctor & Gamble, and ICOS Corp. The study was potentially biased by financial interest, the analysis far from best practice, and the statistic misleading, but it was too late. Journalists had already run with the 43% figure, leading clinicians in the field of women’s sexual health such as Dr Irwin Goldstein and Drs Jennifer and Laura Berman backed it up, and Oprah Winfrey declared it fact. Suddenly America was engulfed in an epidemic of sexually dysfunctional women and the pharmaceutical companies began a race to find a cure.
Such a dysfunction, according to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, to which FSD was a recent addition, could manifest in a variety of forms: hypoactive sexual desire disorder (lack of desire), sexual aversion disorder (avoidance of genital contact), sexual arousal disorder (inability to achieve or maintain an aroused state), orgasmic disorder (absence of orgasm), dyspareunia (pain during intercourse), and vaginismus (involuntary contraction of the perineal muscles when penetration is attempted).
Although the symptoms amounted to the same thing – the lack of interest in or inability to have sex – the causes were unknown. Pfizer was already trying its blockbuster treatment for male sexual dysfunction, Viagra, on women, but so far the studies showed that, though it increased genital blood flow in some women and, therefore, made intercourse possible, it did little to their levels of desire. Women, it seemed, needed more than an increase of blood flow to the vaginal walls to excite them.
Companies sought and failed to obtain Food and Drug Administration (FDA) approval with Flibanserin, an anti-depressant remarketed as an FSD treatment, but with side effects including fainting, fatigue and depression, its risks and benefits were considered unacceptable; a transdermal testosterone patch withdrawn due to concerns over its safety data; and Libigel, a testosterone gel that failed to outperform its placebo.
To date there are only two treatments for FSD that have received FDA approval: Premarin, a vaginal cream for postmenopausal women manufactured from conjugated estrogens isolated from pregnant mares’ urine by Wyeth Pharmaceuticals (owned by Pfizer since January 2009) with warnings regarding stroke, coronary heart disease, venous thromboembolism, and endometrial cancer; and the eros clitoral stimulator, a small vibrator with the added (useless) bonus of FDA approval.
Other treatments are in various stages of development. Lybrido combines testosterone with a phosphodiesterase inhibitor (PDE5), a combination intended to increase sex drive and genital sensitivity; Lybridos combines testosterone and buspirone to treat women who FSD and sexual inhibition, the former intended to increase sex drive and the latter to lower inhibition; both are taken sublingually. LibiGel is a testosterone gel intended for postmenopausal women; Tefina is a nasal testosterone spray intended to provide women with orgasmic disorder an on-demand treatment; Alprostadil (Femprox) is a vasodilatory vaginal cream; Apomorphine is an oral treatment for arousal disorder; Bremelanotide is being tested as a subcutaneous treatment for premenopausal women after development as a nasal spray was stopped due to adverse effects on blood pressure; Intravaginal Dehydroepiandrosterone (DHEA) suppositories are being investigated for the treatment of vulvovaginal atrophic changes and possible effects on hypoactive sexual disorder; Ospemifeme is a novel estrogen agonist and antagonist being investigated as a treatment for painful intercourse; and the Viveve Procedure is a monopolar radiofrequency thermal therapy designed to tighten the vaginal walls after childbirth. How close any of these treatments will come to providing a treatment for FSD or gaining FDA approval remains to be seen. So far, the strength of the efficacy data varies.
There are a number of issues surrounding the emergence of FSD and the attendant rush by pharmaceutical companies to find a treatment: diagnostic procedure, company motivation, clinician financial interests, and the origins of the condition as a disorder, to name a few. The area on which I intend to focus is the concept of objectivity in the treatment of the condition.
Having decided that women required more than physiological assistance to aid them with sexual problems, the notion of desire was introduced into the study and treatment process. (This contrasted with the treatment of men who, it was assumed, suffered no lack of desire – only anatomical malfunction.)
When scientists in the sexual health field study female desire, their intention is to determine what arouses women. They study their physical responses to visual and audio stimuli, their professed desires, and their fantasies. When they examine their results they look for correlations and discrepancies between what women say turns them on and what their bodies respond to. Dr Meredith Chivers is one such scientist who carried out a study in which participants were shown clips of heterosexual, gay, and lesbian pornography, a naked woman exercising, bonobos mating (with chimpanzee hooting dubbed in to make up for the lack of sound made by the mating monkeys), and a naked man with a flaccid penis walking along a beach. They were given a keypad on which to rate their arousal and a plethysmograph, a small plastic probe to measure blood flow to the vaginal walls, was inserted into their vagina. What Chivers found was remarkable. “No matter what their self-proclaimed sexual orientation, they showed, on the whole, strong and swift genital arousal when the screen offered men with men, women with women and women with men. They responded objectively much more to the exercising woman than to the strolling man, and their blood flow rose quickly — and markedly, though to a lesser degree than during all the human scenes except the footage of the ambling, strapping man — as they watched the apes. And with the women, especially the straight women, mind and genitals seemed scarcely to belong to the same person. The readings from the plethysmograph and the keypad weren’t in much accord. During shots of lesbian coupling, heterosexual women reported less excitement than their vaginas indicated; watching gay men, they reported a great deal less; and viewing heterosexual intercourse, they reported much more. Among the lesbian volunteers, the two readings converged when women appeared on the screen. But when the films featured only men, the lesbians reported less engagement than the plethysmograph recorded. Whether straight or gay, the women claimed almost no arousal whatsoever while staring at the bonobos.” (Daniel Bergner, What Do Women Want?, New York Times, January 22, 2009) Women’s desire, it seemed, was a mysterious thing – even to themselves.
The findings of such studies as Chivers’ complicate attempts to find a treatment for FSD. Or, at least, they should. The extent to which pharmaceutical companies, looking to find an easy fix for a vast number of sufferers (read: huge market) would have any intention of exploring the complexity of women’s sexual desire is debatable. Women diagnosed with Hypoactive Sexual Desire Disorder (HSDD), the most common disorder, are said to have deficient fantasies and desire – for there to be a deficiency, there first needs to be a standard of expectancy or normalcy. This is problematic because there is no way of measuring sexual normalcy that isn’t, in some way, influenced by societal factors. Even a basic numerical study to determine the average number of times per week a couple has sex is complicated by factors such as age, sexuality, definition of sexual activity, and health. There is also the influence of attitudes, both personal and societal. Gayle Rubin created the “Charmed Circle” to show the divide between acceptable sex acts – monogamous, hetereosexual, bodies only – inside the circle and unacceptable sex acts – multiple partners, homosexual, sex toys – outside the circle. It’s a simple and, in some aspects, slightly out-dated model, but it illustrates the point that there is no coherent view of sexual normalcy. Yet normalcy is what every pharmaceutical company searching for a treatment is promising women it will bring them.
This is a point in the treatment of FSD at which the significance of the concept of objectivity can be seen. Women seeking treatment for FSD are asked about their levels of sexual desire and the content of their fantasies. They speak to drug trial organisers about how often they and their partner used to have sex and the infrequency with which they do so now; to analysts about their longing to feel desire and desired; to researchers like Chivers about what they believe turns them on; and to clinicians about the vaginal pain that stops them being able to have sex. All these women feel sexually faulty: they believe that, however it is they’re supposed to feel about sex, whatever standards they’re supposed to be reaching, they’re failing to do so. The existence of sexual desire predates homo sapiens (or we wouldn’t exist), but the study of it is very much a contemporary phenomenon. It follows that the studies carried out and the conclusions drawn are likely to reflect the time at which they were done. Had Chivers’ study been conducted at another time, the content of the pornography used could have been quite different and who knows whether or not it would have elicited the same responses?
The sexuality that women are being encouraged to experience by pharmaceutical scientists is worth some unpacking. The marketing for Viagra promoted the manly man – capable, strong, spontaneous, he would surprise his wife by trading in his car for a motorbike and whisking her off or use the horses in his trailer to pull the truck out of mud so he’d be able to get home to her. He’s monogamous and willing to talk about sexual problems, implied by the fact that he’s spoken to his doctor about erectile dysfunction and got a prescription for Viagra. The leading competitors in the erectile dysfunction market, Cialis and Levitra, promote a similar figure.
What figures and scenarios will be used to promote an FSD treatment to women? If Chivers is right and women are aroused by such a range of stimuli, it should be a veritable panoply. Possibly not bonobos, but all manner of sexual arrangements appeal to women: one-night stands; same sex dalliances, flings and relationships; polygamous relationships; monogamous relationships; relationships across ages. Will there be images of groups of women out on the town and looking for some action or will they all be padding off to bed in soft focus with a sole male partner? Treatments for erectile dysfunction have never been marketed at gay men so will the companies avoid lesbians in their marketing?
During the clinical trials and in consultations for erectile dysfunction treatment, men have been asked about their ability to attain and sustain an erection and whether or not this erection was sufficient to penetrate their partner’s vagina. There are no questions in the criteria for the diagnosis of erectile dysfunction pertaining to how much time they spend thinking about sex or what they think about – for men, it is about function, not fantasy. Yet for women, a key component in the diagnosis of the most common form of dysfunction, HSDD, is the presence or absence of sexual fantasy in their lives. If drug companies are prescriptive about the sort of sexual behaviour they encourage through their marketing, will they also encourage clinicians to behave in a similar manner during diagnosis? Perhaps certain sorts of fantasy or desires will discouraged or will disqualify women from treatment. Fantasies that suggested abuse or rape, for example. In my opinion, for which the only qualification I have is that of being female, the rape fantasy in women is from a narcissistic urge to be desired so strongly by a man he is unable to control himself and has nothing to do with the reality of rape. It’s an ersatz rape, if you will – a role play of non-consensual sex between consenting partners. Women are asked about their fantasies, but what would happen if men were asked the same? Would a man who admitted to fantasies of rape still be prescribed Viagra or would he be denied it on the grounds of a fantasy he might never enact?
Perhaps there is no purpose to be served in looking or hoping for objectivity in the study of female sexual desire. Vested interests in women’s favour might actually make for a more favourable outcome to any research than the declared objectivity of scientific method. As Sandra Harding puts it, “…how should one explain the surprising fact that politically guided research projects have been able to produce less partial and distorted results of research than those supposedly guided by the goal of value-neutrality? Second, how can feminists create research that is for women in the sense that it provides less partial and distorted answers to questions that arise from women’s lives and are not only about those lives but also about nature and the rest of social relations?” (Sandra Harding in Feminist Epistemologies: 49-50)
Scientists researching pharmaceutical treatments for FSD are focusing their efforts on women’s endochrine systems and sex organs. They may have decided that women need more than simply an increase of blood flow to their vaginal walls to arouse them and that the causes of the disorder might lie outside anatomy, but they are still using it as their primary source of knowledge about women’s sexuality. If they have any hope of finding a way in which to treat FSD, they need to look to the knowledge created by the women themselves.