Bad MedicineBig Pharma’s Female Trouble

A transmasculine gender-nonconforming person caressing the face of a transfeminine nonbinary person (The Gender Spectrum Collection)

This article was published in Hot & Bothered Issue #33 | Fall 2006

Call it Viagra culture: In the eight years since the little blue pill made the scene, its wild suc­cess has institutionalized the impulse to treat any and all sexual problems, idiosyncrasies, or irregularities with prescription drugs. The result is an increasingly commercialized approach to sex that turns attention away from the complex social, cultural, and psychological determinants of sexuality that have been the subject of feminist analysis for several decades. Feminist activists and scholars have long observed that sexuality—especially, but not exclusively, women’s sexuality—is as much a matter of politics as biology. But in their effort to medicalize sexuality, big pharmaceutical companies want us to believe that sexual problems are a result of biology alone.

Of course the drug industry wants us to believe that the solution to our sexual woes lies in a pill/patch/cream/nasal spray; after all, a pill that puts orgasms easily within reach can be marketed in a profit-making system, but social change is a little trickier. The first success of Viagra culture, apart from the drug itself, has been the success of drug companies in successfully banishing the term “impotence,” with all its psychological connotations of weakness and failure, and replacing it with the more biologically oriented, less judgmental “erectile dysfunction,” or ED. And in the hopes of doubling their profits by doubling their market, pharmaceutical companies are now working toward their second challenge—reconceptualizing women’s sexual problems as physiologically based “female sexual dysfunction,” or FSD.

So far, no “pink Viagra” has yet received approval from the Food and Drug Administration, but dozens of prod­ucts are in development, and each year growing numbers of women are given off-label prescriptions of men’s sex drugs, even though these drugs have not been proven safe or effective for women. (Despite the popularity of Viagra as a party drug for gay men, Big Pharma’s marketing and research programs betray a deep heterosexual bias. The current research on FSD in particular tends to focus almost exclusively on heterosexual women, relying on a heterocentric view of sex and implying that only certain women’s sexual problems—and only certain kinds of sexual problems—are worthy of consideration.)

The year 2003 marked both the fifth anniversary of Viagra’s launch and the release of two prominent new sex drugs for men, whose names will be familiar to any email user: Levitra and Cialis. All these drugs are intended to treat ED, a condition made famous by those first Viagra ads featuring an aging Bob Dole confiding in us about his post-prostate-surgery erection troubles. Nowadays, drug makers are seeking ways to distinguish their ED products in an increasingly competitive marketplace. Pfizer, the maker of Viagra, realized it needed sexier ads to capture the younger set, and soon dumped Dole as its poster boy in favor of highly masculine (and less wrinkled) professional baseball players and NASCAR drivers.

The ads for Levitra and Cialis, however, have attempted to secure a portion of Viagra’s multibillion-dollar annual market share by literally bringing women into the picture: Prominent ads from the Levitra campaign feature a female partner front and center, talking about her man’s concern with erection “quality,” the silent male demoted to the background. Cialis capitalizes on its alleged 36-hour range of effectiveness by depicting a heterosexual couple enjoying an air of romance (“If a relaxing moment turns into the right moment, will you be ready?”), with one of its first ads showing a couple enjoying the view from their his-and-hers bathtubs.

But pharmaceutical companies want women to be more than the spoonful of sugar that makes the medicine go down for their male partners; they want women to spend an equal amount of time worrying about their own sexual problems and what pill might treat them. Female sexual dysfunction is listed in the Diagnostic and Statistical Manual of Mental Disorders (the official catalogue of mental illnesses), so if a woman is diagnosed with something that falls under the umbrella of FSD (say, lack of desire, lack of arousal, pain during intercourse, or lack of orgasm), she is automatically considered to have a mental illness or disorder. A few generations ago, a woman might be considered mentally ill (more specifically, a nymphomaniac) if she wanted sex too much; these days a woman might just as easily be labeled mentally unsound if her libido is below “normal.”

For years, Pfizer hoped to determine that Viagra could be used to counter low arousal in women, but in 2004, the company stopped its clinical trials, concluding that Viagra was no more effective than a placebo. (The placebo, by the way, did have a positive effect on sexual arousal, suggesting, if nothing else, the important role of expectation in psychology.) But why have women share the men’s candy when an FDA-approved sex drug specifically for women could be just as much of a marketing boon as Viagra was? With a market for such medical treatments at an estimated nearly $2 billion per year, pharmaceutical companies have a tremendous financial incentive to produce a successful contender, and thus far more than half a dozen companies are focusing their efforts on drugs intended to treat low desire and arousal, developing and testing a raft of pills, patches, creams, and sprays, hoping to find that elusive pink Viagra.

The main focus in FSD-drug development is on testosterone products intended to amp up sexual desire, rather than the Viagra model of products that increase blood flow to the nether regions. Just months after Pfizer pulled the plug on the Viagra trials targeting women, Proctor and Gamble announced plans to seek FDA approval for its Intrinsa testosterone patch, designed to remedy a lack of desire in women. Mainstream media obediently followed Proctor and Gamble’s marketing spin—it’s not sexual arousal that’s the problem, it’s desire for sex to begin with—proclaiming the failure of the Viagra trials to be evidence of women’s complex sexuality. Testosterone—often called the “hormone of desire”—seemed like the most promising fix.

Though low sexual desire in women is often considered to be a product of testosterone deficiency, this assertion has not been borne out by evidence; a 2005 article in the Journal of the American Medical Association explicitly debunked the notion of a link between low sexual desire and low testosterone levels in women. In December 2004, the FDA reviewed the first-ever application for an FSN-specific drug—the aforementioned Intrinsa patch. The FDA’s advisory committee determined that the benefit of the drug (an average of one additional sex act per month, according to the trials) was overshadowed by the patch’s potential long-term health risks, and they unanimously voted against approval of Intrinsa.

Yet despite the lack of scientific data on the efficacy of testosterone to treat low libido in women, the absence of FDA approval of use of testosterone to treat these problems, the known risks of testosterone therapies for women (ranging from beard growth to more health-threatening liver problems), and the unknown long-term risks of such therapies, a growing number of physicians are prescribing testosterone drugs off-label to women. (If a drug is FDA-approved for any one condition, a doctor is allowed to prescribe it off-label at her discretion for any other condition, even if the drug has not been tested or approved for that condition.)

In an October 4, 2005, article in Newsweek, testosterone researcher Dr. Jan Shifren estimated that one-fifth of all prescriptions of testosterone products approved for men are actually written off-label for women  for the treatment of “sexual dysfunction.” Such off-label prescribing is becoming increasingly normalized in mainstream media accounts of FSD, and depicted favorably in outlets such as CBS Evening News and 20/20, as well as in numerous women’s magazines. Women in search of solutions to their sexual problems often turn to the mass media, looking to magazines and television talk shows for advice, information, and empathy. But because many of these sources encourage women to see disappearing libidos or foiled orgasms as de facto FSD, these encounters often work to spread the Viagra culture, to the detriment of the women themselves.

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Two sexperts have risen to particular prominence in this coverage of FSD, largely through their presence in pop venues: sex therapist Laura Berman, PhD, and urologist Jennifer Berman, MD. The Berman sisters have been favorably featured in numerous women’s magazines, including Cosmopolitan, Marie Claire, and Ladies’ Home Journal; appeared on many TV shows, such as Good Morning America, the Oprah Winfrey Show, and 20/20; and had their own weekly cable-TV talk show on the Discovery Health Channel. (Laura has a reality show called Sexual Healing upcoming on Showtime.) With cowriters, they’ve published two mainstream books on women’s sexual problems: For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life and Secrets of the Sexually Satisfied Woman: Ten Keys to Unlocking Ultimate Pleasure.

In 2001, the Bermans founded the UCLA Female Sex­ual Medicine Center. Three years later, Laura Berman left UCLA to open a private clinic, the Berman Center, in Chicago. Jennifer Berman soon followed suit, opening a sexual-medicine practice in Beverly Hills at the Rodeo Drive Women’s Health Center. The shift of the Bermans’ practices from an academic center to the explicitly for-profit commercial sector speaks volumes about the new retail-oriented cultures of both sex and medicine. Both practices offer a boutique experience in a high-end, spa-like environment. A review of the Berman Center’s website, where a prospective client can secure an appointment with a credit-card number, indicates that an initial assessment will cost $550 plus testing, and another $550 will buy a session of “bioidentical hormone therapy.” Not surprisingly, there’s no mention of insurance coverage. (There’s already been a lot of outrage in feminist and women’s health circles about the fact that Viagra is more likely to be covered than contraceptives, and one can easily imagine that insurance companies might similarly refuse to cover sex drugs for women, even if they are eventually FDA-approved.)

Even more important than the commercialized nature of the Bermans’ practices, however, is their approach to treatment. Although both assert that they combine the strengths of psychotherapy with the benefits of sexual medicine, they ultimately give preference to the biomedical perspective. As part of a 2004 20/20 special on women’s sexuality, the Bermans treated a woman whose husband had threatened to leave her if she didn’t remedy her low mojo.  Though the sisters failed to find any biophysical indications for the woman’s depressed libido (in other words, no sign of “low” testosterone), they nevertheless wrote a prescription for testosterone and, with this magic bullet, sidelined the deeply problematic nature of the woman’s relationship with her husband and any psychological factors that may have affected her sex life.

The spread of an already prevalent “just pop a pill” approach to the realm of sexual desire minimizes the myriad ways in which our society fosters sexual problems in both women and men. People work more hours in the United States than in any other industrialized society, take fewer vacation days, and have increasingly longer commutes—so exhaustion alone is quite possibly a major explanation for many an underused American bed. But for women, the same political struggles that have long informed their sexual choices and well-being are still in existence.

The spread of an already prevalent “just pop a pill” approach to the realm of sexual desire minimizes the myriad ways in which our society fosters sexual problems in both women and men.

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Persistent gender inequality in heterosexual couplings (manifested in women shouldering much of the burden of household work and childcare), an increasing threat of restricted reproductive rights, an active epidemic of sexual violence against women, and women’s higher likelihood of being diagnosed with depression (and higher rates of antidepressant use) all likely play a role. In addition, women’s magazines’ continual emphasis on sex and how to make it longer, better, and more frequent can easily give women the impression that they’re at fault if they can’t blow their man’s mind—to say nothing of their own—every time. Certainly, a sex drug won’t address these fundamentally social and cultural causes of sexual discontent. Men, of course, can also experience sexual problems for many of these same reasons as well, a point usually minimized in discussions of ED.

As the medicalization of sex expands, growing numbers of critics are raising voices of dissent. Since its 2000 inception, the New View Campaign has used a variety of tactics to counter the growing biomedical orientation surrounding women’s sexuality (see www.fsd-alert.org). Critical articles about FSD have also appeared in medical journals, such as the British Medical Journal, and a number of mainstream publications, including 2005 features in the Seattle Times and the Los Angeles Times. And recent drug scandals, such as those involving the Vioxx brand pain reliever and hormone replacement therapy, appear to be ushering in a more widespread critical appraisal of the health threats of our pill-popping culture.

Perhaps the biggest danger of the rise of Viagra culture is that the source of women’s sexual problems is becoming overtly depoliticized. A main intent of the feminist women’s health movement was to politicize women’s sexual/health problems, often by challenging the power of the medical establishment. Now that drug companies are the major players hijacking the characterization of women’s sexual problems, we need to firmly resituate women’s sexuality back into the political realm. Sure, some women may be helped by a new sex patch or pill, but this quick fix (with health risks) might just put a Band-Aid on a larger problem. Neither the medical establishment nor the drug industry is going to change, so it’s time for women to demand that these profit-hungry entities stop trying to peddle drugs that benefit their bottom line at the expense of our health.


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by Heather Hartley
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Heather Hartley was an associate professor of sociology at Portland State University, where she taught courses on health, gender, and sexuality.