London School of Hygiene & Tropical Medicine

I was disheartened to learn last week that the US Federal Drug Administration approved flibanserin for treatment of low female sexual desire. The decision was claimed as a victory for women. But as a researcher working in sexual dysfunction and interested in the medicalisation of sex, the victory tasted a little bitter.

Flibanserin (marketed as ‘Addyi’) is hailed as ‘Viagra for Women’ or the ‘Pink Viagra’ but this is misleading. Where Viagra targets difficulties with getting an erection and acts to increase blood flow to the genitals, flibanserin targets problems with desire and acts on the central nervous system. Whereas the mechanism of action for Viagra is known and understood, flibanserin is a failed anti-depressant and no one really understands how it works. And whereas around 70% of men respond to Viagra, less that 15% of women are likely to respond to flibanserin. The benefits for those who do respond are marginal; around one more ‘satisfying sexual event’ per month over and above placebo.

The medical profession has expressed grave concerns about the side-effects which include drops in blood pressure, fainting and dizzy spells. These events are made worse by alcohol; the drug most commonly associated with sex.  Flibanserin has been approved only for use in pre-menopausal women with clinically diagnosed sexual desire disorder and no alcohol use. Despite this, a leading sexual dysfunction doctor has already been on record saying he would not deny the drug to casual drinkers.

Sprout pharmaceuticals brought flibanserin to the table, despite two previous failed attempts at approval by other companies. The ostensible mission was to “even the score” for women, for whom there are no approved drugs for sexual dysfunction compared with 26 for men. It is a battle cry that resonates with many women, particularly those who struggle with distressing sexual problems. The “Even the Score” campaign is supported by several women’s organisations but has also received financial backing from the pharmaceutical industry (including Sprout) and has been criticised as a pharma-funded public relations campaign.

There is something deeply cynical about co-opting language of inequality in order to promote a pharmaceutical product. Of the 26 drugs available for men, most are variants of testosterone and there are serious concerns about the side effects of these. There is an implicit assumption that more medicine can only be better and that sexual problems can be fixed with a pill. My research over the past few years suggests that neither assumption is correct.

With colleagues from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), I recently published an article describing the extent of medicated sex in Britain. We found that 2% of women had used medicine at least once to enhance their sexual performance (and 13% of men). It is not clear what these women were taking since at the time of the survey, there were no approved drugs for women on the market.

Our results, and those of other researchers, suggest that the risks of medicated sex are wider ranging than drug side effects. Among men, we found an association between medicated sex, unsafe sex and sexually transmitted infections, suggesting the need to tread carefully when promoting pharmacological solutions. Research also suggests that using medication to enhance sexual performance can be detrimental to men’s sexual confidence, can lead to increasing dependence on drugs, and can give rise to unrealistic expectations of sexual performance. It seems likely that women would experience these downsides too.

As part of my PhD at the London School of Hygiene & Tropical Medicine, I asked a range of individuals to define what they saw as a ‘good-enough’ sex life. I was impressed by the variation in individual priorities and the number of different ingredients of good-enough sex suggested across the group (31 in all). Where participants had encountered problems, there was an equally impressive range of perceived causes. The causes of low sexual desire in women include negative childhood experiences, inadequate knowledge, relationship strain, and unrealistic expectations. A pill cannot of course address these problems, but it is very human to hope that it will. Even the drug companies recognise the multifaceted nature of sexual function (the extent to which an individual is able to participate in and enjoy a sexual relationship) and yet public appetite and corporate energy for a single-bullet solution seems boundless.

Flibanserin may work for some women, but I know of a potential fix that I suspect may be more powerful and far less risky: being able to talk openly and confidently with your partner about sex. Our Natsal data suggests that ease of talking about sex with a partner really matters to good sexual function. And if it was about evening the score, the fix might focus on equipping women to talk about what gives them pleasure. But communicating with ease requires a degree of comfort with your sexuality, may make you vulnerable and requires lots of effort; you can’t package the skills in a little bottle and there’s no big money to be made. Flibanserin is what many women want but they should be careful what they wish for….

Publications:

• Kirstin R Mitchell, Philip Prah, Catherine H Mercer, Jessica Datta, Clare Tanton, Wendy Macdowall, Andrew J Copas, Soazig Clifton, Pam Sonnenberg, Nigel Field, Anne M Johnson, Kaye Wellings, Medicated sex in Britain: evidence from the third National Survey of Sexual Attitudes and Lifestyles, Sexually Transmitted Infections. DOI: 10.1136/sextrans-2015-052094
• Kirstin R Mitchell, Catherine H Mercer, George B Ploubidis, Kyle G Jones, Jessica Datta, Nigel Field, Andrew J Copas, Clare Tanton, Bob Erens, Pam Sonnenberg, Soazig Clifton, Wendy Macdowall, Andrew Phelps, Prof Anne M Johnson, Prof Kaye Wellings, Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), The Lancet. DOI: 10.1016/S0140-6736(13)62366-1

Image: Couple talking. Credit: Freeimages.com/Dora Pete