Sex Science: The Making of a Disease by Brooke Magnanti (part two)

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In the last column  I discussed the growing attention the pharmaceutical industry is giving to the newly-defined “disorder” of Female Sexual Dysfunction (FSD), and the criticisms of it.

While the industry quotes impressive numbers about the percentage of women afflicted with FSD, it’s worth asking how they define their terms. It’s also worth asking whether the people being pathologised – the women now being told they are experiencing a disorder – are actually feeling distress from it.

Studies have uncovered a gap between the number of women who can be potentially diagnosed with FSD and those who seem to actually have a problem. A study in London compared the newly developed diagnosis against the number of women who felt they experienced negative sexual dysfunction effects. While using the diagnostics found 38% of women had sexual dysfunction, only 18% of the women thought their symptoms concerning – and just 6% rated it ‘moderate’ or ‘severe’. Surely, if there is a problem with lack of desire for sex, the best placed person to decide whether it’s severe or not is the woman herself .. . not some arbitrary clinical scale.

A Swedish study confirmed that less than half of women who reported decreased interest in sex over time considered themselves dissatisfied. Another study by Irwin Nazareth in London looked at subjects recruited from GP surgeries and suggested that in people who could be diagnosed with a sexual dysfunction, ‘reduced sexual interest or response may be a normal adaptation to stress.’ In other words, could what is being labelled as a disorder actually be a natural ebbing and flowing of desire over time?

What would be the reasons for such disagreement between the diagnoses and the number of people reporting problems? One reason could be that people were not discussing their problems with GPs – possible, but the Nazareth et al. study suggested that patients are pretty honest with their doctors when it comes to sexual difficulty. While it is plausible that people who speak to their GP about problems with sex are a self-selecting group, making the study an undercount of people with the syndrome, there is no easy way to correct this. The ‘dark art’ of estimating unknown populations is a much misunderstood, and sometimes abused, approach to diagnosis.

Another reason could be that the criteria are defined too broadly. In some cases it looks like even an occasional event merits a scary diagnosis. But what would be the benefit of overdiagnosing the population? Some diagnostic manuals, such as the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), have been criticised for possible conflict of interest between the committees who write the disease definitions and the pharmaceutical companies selling prescription drugs. Half of the people on the DSM committees have some kind of connection to a drug company. On the committees writing definitions for some areas of disorders, the figure shoots up to almost 100%.[]

Because of their controversial nature, there has been a push to reconsider the criteria for sexual dysfunction – considerations that may be reflected in the upcoming DSM-V. According to a paper by Richard Balon and Anita Clayton, ‘Marked distress or interpersonal difficulty is a criterion of all DSM-defined sexual dysfunctions,’  since this helps determine what is and is not normal. But if large numbers of women being diagnosed say they are not distressed, then how can the diagnosis be real?

So it’s unsurprising that drugs hyped as potential ‘female Viagra’ have not done well. Along with the failure of Viagra-like vasodilation drugs and hormone treatments, drugs that target neurotransmitters have also failed to have an effect. Procter & Gamble’s experimental testosterone patch was rejected by the US Food and Drug Administration in December 2004. The German drug company Boehringer stopped developing its drug flibanserin after unsuccessful clinical trials in North America. []

The assumptions made by the industry and the researchers they influenced all follow old stereotypes. The drugs either try to increase vaginal blood flow (implied: women don’t get turned on easily, so drug intervention is needed), or they try to boost testosterone (implied: women don’t have hormones like men’s, so drug  intervention is needed). Others focus on neurotransmitters (implied: there’s some- thing lacking in women’s brain chemistry, so drug intervention is needed).

Characterising natural variations in women’s libidos as a problem that needs to be solved is nothing new. What is novel is the interest from big pharmaceutical companies in getting involved on a commercial scale. In the 1966 book Feminine Forever, author Robert Wilson suggested that the menopause is a ‘disease’ of female hormone deficiency and that good sexual health could be saved by taking hormones.  Wilson’s writing was hugely influential. In the following decades, hormone replacement became a popular option for Western women above a certain age. It’s a treatment that is far from cheap and demands constant upkeep, and has been linked with negative side effects including cancer and heart disease.

Hormone replacement and its supposed benefits, particularly for older women’s sex lives, however, are at odds with the experimental evidence. With their famously extensive laboratory research, Masters and Johnson showed in 1970 that ‘nothing could be further from the truth than the oft-expressed concept that aging women do not maintain a high level of sexual orientation.’ The menopause does cause thinning of the vaginal walls and decrease in lubrication, but the studies found no decrease in clitoral function, which is the real cause of orgasm

Undoubtedly there are women who do suffer from sexual problems, and over the course of a lifetime, this can affect a large proportion of people at some point or another. But claiming it’s a disease in approximately half of all women all the time? Not only does this exploit old stereotypes about women and lack of desire, it’s a strategy that hardly helps the smaller proportion of women who are distressed and might actually benefit from targeted and sensitive treatment.

The characterisation of variations in female libido as a dysfunction has not led to a pharmaceutical success. This hasn’t stopped the pharma agenda, however – far from it.

The World Congress for Sexual Health, held in Glasgow in June 2011, attracted sexual health experts from all over the world. Papers presented at the conference were published in the prestigious Journal of Sexual Medicine. Alongside the research areas you might expect at the conference, like HIV prevention, teenage pregnancy, and gender and sexuality there was a session entirely devoted to ‘Hypoactive sexual disorders among women and pharmacological treatments’. One of the major exhibitors supporting the conference was the drug company Bayer, which has been developing and marketing an intra-vaginal drug meant to treat (wait for it) . . . female sexual dysfunction. []

But here’s the thing. While an industry presses on with its erroneous pharmaceutical solution, research indicates there may be a real, and cheap, way to address the problem for those who are actually experiencing discomfort with the changes in their libidoes.

Studies of treatments for FSD that only take a pharmaceutical approach have been negative or mixed. Studies that include erotic images, however, have been far more successful in getting results. Postmenopausal women on oestrogen-replacement treatments were treated with sildenafil (the generic name for Viagra) in an attempt to restore orgasmic ability. [] While the drug on its own did not do much, the study also combined pharmaceutical treatment with watching porn. The paper notes that ‘[t]he erotic video significantly increased subjective sexual arousal in all women’ but that they ‘do not benefit from sildenafil’.

Or in other words, put a sexual context back into women’s lives, stop harping on about a supposed dysfunction, and before you know it they may start to sexually respond. It’s not really all that surprising, is it?

A pity for Big Pharma that they aren’t in the business of producing porn films. Or at least, they aren’t . . . yet.

Brooke Magnanti is author of The Sex Myth which explores many fascinating myths about sex

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