In its latest attempt to kick-start lady libidos with a pill, Sprout Pharmaceuticals announced this week that it will resubmit its female sex drug, flibanserin, for FDA approval. If it gets the okay, the drug would be the first prescription of its kind for women in the United States: a treatment for female hypoactive sexual disorder, or a low sex drive.
More than a dozen drugs that address some kind of sexual dysfunction already are available in the US. But since Viagra’s little blue pill hit the market, nearly all of the approved sex drugs have targeted men, despite the oft-cited statistic that nearly half of American women report some sexual dissatisfaction —notably more than their counterparts. While the FDA has approved medications for women that ease sex-related pain post-menopause, it hasn’t approved a more general sex aid, like the erectile dysfunction drugs available for men.
Patients, doctors, and activists have called this imbalance sexist, and the FDA has named female sexual dysfunction a top priority “disease area.” (To be clear, there are also no drugs for men that target perceived problems with the desire for sex, just the hydraulics that make erection possible.) But for Leonore Tiefer, an outspoken clinical associate professor of psychiatry at NYU, the lack of drugs isn’t the problem—we are.
After a lengthy career as a sex therapist, Tiefer has spent more than a decade arguing against the aggressive labeling of so-called sex disorders and the impulse to treat them with drugs. She blames the country’s medicalization of sex on a pharmaceutical industry hellbent on driving profit by stoking anxieties about “normal” sexual behavior—not to mention aggressive advertising campaigns, media, and news stories marginalizing diverse and individual desires.
Now, as companies like Sprout test dozens of products for women—pills, vaginal gels, even nasal sprays—in a race to sell the first “pink Viagra,” Tiefer asks us to question if we need it at all.
When did people start asking, “Okay, where’s the sex drug for women?”
Three months after Viagra was approved in 1998, The New York Times ran a front-page article about it. Nobody I knew was asking that question. I think the media wanted a different angle—the media kind of lost it entirely when Viagra was approved.
But 17 years later, we still don’t have one. Why?
No one really knows—for men or women—how desire and arousal work. There’s no research that tells you where a woman’s desire spot is. Except for the clitoris, and nobody’s working on that at all.
If there’s no medical foundation, how are researchers making these drugs?
Pharmaceutical companies first tried Viagra’s strategy: vasodilators, which they claim work to expand blood flow to the penis and other parts of the body. They caused tingling and enlargement of the clitoris and the labia—but women said it didn’t do anything for them. So they abandoned that.
After vasodilators failed, companies thought let’s try hormones—that’s always popular. So they did a million studies on testosterone and announced intrinsa, a testosterone patch, in 2004. But it didn’t pass the FDA’s tests. And then there was flibanserin, which targets neurotransmitters. That was originally rejected in 2010.
Flibanserin is now in the process of being refiled to the FDA, but it’s already been rejected twice. Why has the FDA rejected these kinds of drugs in the past?
They can have side effects—cardiovascular effects, cancer effects. They also have to be taken chronically—as opposed to Viagra, where’s it’s pop one and you’re out. And they weren’t better than the placebos. These drugs “work” for some women in the same way that Viagra “works” for some men. Every sex drug, including Viagra, has an inordinately high placebo rate. A lot of people hope it will work, expect it will work, and then they feel better. But—it’s a well-kept secret—the represcription rate for Viagra is less than half. It doesn’t work all that well, and the side effects are extremely annoying. We still don’t even know whether blood flow is really the main mechanism of action.
If it’s not that effective, how has Viagra become so popular?
Viagra was the first drug to really take advantage of direct-to-consumer advertising, especially on TV, after the FDA loosened restrictions in 1997. The pharmaceutical industry underwent a big change in the ’90s from focusing on diseases to focusing on lifestyle issues. But the lifestyle issues, like weight and sleep loss, had to be framed as medical conditions to fetch the high prices of medications.
So since the ’90s, conversations about sexuality have become much more focused on achieving “normal function,” the necessity of “normal functions,” the rewards of “normal functions.” Viagra has turned the public understanding of sexuality in a direction that I don’t think is beneficial. But, from the industry’s point of view, it’s all about profits. There’s nothing complicated about that.
Why isn’t there a normal function when it comes to sex?
There’s an assumption that sex is a built in thing, like digestion. And if something’s wrong with the body’s natural processes, we have this modern notion that you take something to fix it. But it’s not at all built in! An erection is built in, for the most part, but how you’re supposed to feel, or what you’re supposed to do about it, or how often, or with whom? None of that’s built in.
But isn’t sex an instinct?
Sex is like dancing. You’d never say dancing is the same in China as it is in Peru. You would never say the dancing that a 20 year old does is the same as the dancing a 60 year old does. I don’t think sex is a matter of health. If there is no normal healthy sex, then there can’t be diseases. There can’t be treatments.
Men have treatments. If women are unhappy with the sex they’re having, shouldn’t they have options, too?
I definitely think people should have what they want out of life, but I don’t think they should be misled about what kind of a thing it is. Most people are distressed about their sexual experience because we live in a culture that sets very high expectations and gives people very little preparation. They’re not having the quantity, or the quality, or the intensity that they think other people are having. So should they run to a doctor and say there’s something wrong with them? That’s where I part ways with the medical model.
To me, it seems like a fairness problem—men orgasm most of the time, women don’t. Men have access to drugs, women don’t.
Sure, but I don’t think what feminism has meant by equality is identicalness. I should have as many rights as my partner to say what we do, and when we do it, how often we do it, and I shouldn’t have to do anything I don’t want to do. But that has nothing to do with the equality of number of drugs or orgasms. Why would you want just one measure, especially something that’s not that easy and requires a certain kind of genital stimulation and a certain kind of mental attitude and it only lasts 10 seconds anyway?
Why not give people the option of having drugs if they want them? What do we lose?
Diversity and individuality. Sexuality is potentially an extremely diverse landscape of interests. You’re not allowed to have low interest anymore. Those people are now ill. Without drugs, sex wouldn’t be about intercourse or orgasms, but about physical intimacy, sharing things, the bodies involved. All of that is completely marginalized.
So, if we shouldn’t turn to drugs, how can people improve their sex lives?
There’s no way that I can answer that—if I could, I would put it on a 3×5 card and hand it out on the corner. It’s extremely individual. People think sexuality is something only an expert can help them with, but experts can only help in the way they know how. You take a car to a car repair shop, they deal with it in a mechanical way—they don’t pray over it. Doctors are happy to tell you about blood vessels, but they won’t talk to you about culture or love.