Читать книгу Sex, Lies, and Pharmaceuticals - Ray Moynihan - Страница 10
ОглавлениеOne Difficulties or dysfunctions?
We’re hoping to be able to expedite the process . . . of disease development . . .
—Drug company manager Darby Stephens
The woman looking confidently into the camera lens must be in her late twenties or early thirties, her long black hair falling over strong shoulders, a slip of striped blue material tied into a bow around her neck. Her red lips and good looks are striking, but it’s her words that are most captivating. Her name is Darby Stephens, and she’s a research manager at a California-based drug company called Vivus. The company is testing a drug for women said to suffer from a new condition called female sexual dysfunction or FSD. As Darby Stephens explains in an extremely candid on-camera interview for a documentary, FSD is so new that the drug company itself has had to help work out what the condition actually is: ‘In order for us to develop drugs, we need to better and more clearly define what the disease is,’ she said.1
The frankness of the comments may be unusual, but the marketing activity being described is becoming commonplace. Pharmaceutical companies now assist in shaping the very diseases their drugs are targeting. Through its close ties to the medical profession and its influence over public debate, the industry is now helping to determine whether we see our sexual problems as everyday difficulties or medical dysfunctions, and whether female sex drugs become a permanent feature in the bedrooms of our future.
The Californian company where Darby Stephens was manager of clinical research had started testing a pharmaceutical cream for women to rub on their genitals, to see whether it could enhance blood flow and boost their level of sexual arousal. Before the drug testing could go into full swing, however, there was a problem that needed to be addressed. As Stephens tells it, in order to get a drug formally approved and have insurance companies pay for its use, it has to be shown to work against a specific medical condition: ‘The whole thing is kind of complicated because you have to have a disease before you can treat it.’
The difficulty with FSD was that no one was really certain exactly what the condition was, and some people even questioned whether it existed at all. So part of Vivus’s role, Darby Stephens explained, was to sit down with the experts, the ‘thought leaders’ in the field, and work with them directly on developing this new dysfunction in order to be clearer about what it was. During her frank interview, she revealed that in the ‘process of defining the disease, we’ve been able to get thought leaders involved in female sexual dysfunction, and really work closely with them to develop this disease entity, so that it makes sense’. Her comments were made at a time when drugs for male sexual dysfunction had already been approved, and billions of dollars’ worth were set to sell every year. So from the industry’s perspective, there was no time to waste in developing the sister condition for women. ‘We’re hoping to be able to expedite the process of drug development and of disease development,’ she told film-maker Liz Canner during the interview for Canner’s documentary Orgasm Inc.
Bizarre as it may sound, the idea that a drug company would play a role in ‘disease development’ is backed up by observations from another industry insider, this one with expertise in the practice known as ‘condition branding’.2 The advertising expert Vince Parry famously revealed how drug companies are sometimes involved in ‘fostering the creation’ of medical disorders, giving a little known condition renewed attention, helping redefine or rename an old disease, or sometimes assisting in the creation of a whole new one. The branding expert has said that as part of his high-level work for drug companies he will sit down with medical experts to try to ‘create new ideas about illness and conditions’. As the Canadian writer Naomi Klein told us in her classic No Logo, corporations are no longer just selling products, they are selling brands, and brands are about lifestyles and concepts, not commodities.3
These revelations about drug company plans to accelerate the development of a disease, in order to test and sell drugs for it, herald the opening of a new chapter in the story of the modern medical marketplace, where the corporate sector now works together with leading medical experts to help tell us who’s sick and who’s in need of the industry’s latest cures. But to what extent are women’s problems of desire and arousal really the signs of dysfunctions, or rather common sexual difficulties being portrayed as diseases in order to sell drugs?
One place to start answering the question is to take a closer look at the actual technical definitions of this new sexual dysfunction and its four sub-disorders. Just as some infectious diseases are technically defined by the presence of particular levels of antibodies in the blood, so too dysfunctions and disorders are defined by certain behaviours or characteristics considered abnormal. While we might imagine these medical definitions to be solid and certain, nothing could be further from the truth. This condition is poorly defined and its definitions are constantly shifting and moving—a fact readily acknowledged even by those who write them. Dr Sandra Leiblum, the high-profile psychologist from the Robert Wood Johnson Medical School with first-hand experience of revising the definitions, has eloquently described these shifting sexual sands: ‘the classification of female sexual dysfunction’, she wrote, ‘is somewhat arbitrary, imprecise, and changeable’.4
One of the first things that strike you about this technical definition is that it comes from the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is produced by the American Psychiatric Association, the professional body representing psychiatrists. When it was first released in the 1950s the manual was a small book, but it has become a giant text running to almost 1000 pages, full of many different disorders. While it was an American creation, it is now highly influential around the world. As some readers will already know, the DSM is seen as something of a bible of diseases by many doctors; however, it is also regarded as controversial, coming under heavy criticism for turning the experiences of ordinary life into the signs of medical illness.5 In its pages, severe pre-menstrual pain has become ‘pre-menstrual dysphoric disorder’, a set of common children’s behaviours re-packaged as ‘attention deficit hyperactivity disorder’ and extreme shyness has been transformed into ‘social anxiety disorder’. The DSM has also been criticised for the closeness between the expert committees who write the definitions of diseases and the pharmaceutical companies that sell the drugs prescribed to treat them. One study that looked closely at the affiliations of the men and women on those committees found that more than half of them had ties to drug companies. On the committees revising mood disorders, including depression, the figure was closer to 100 per cent.6
It was only as recently as the 1980s that the term ‘sexual dysfunction’ first appeared in the DSM though sexual ‘disorders’ had been previously listed. Since then, the definitions have changed a number of times, as the manual has been updated and new editions have been published. The details of the most recent definitions now run to many pages, but in simple terms the condition known as female sexual dysfunction, or FSD, has been divided into four sub-disorders: desire, arousal, orgasm and pain. The disorder of low desire is defined as a deficiency in sexual interest or fantasy, and technically described as ‘hypoactive sexual desire disorder’, or HSDD. Arousal disorder is described as inadequate genital lubrication and swelling, in response to sexual excitement. It is termed ‘female sexual arousal disorder’, or FSAD. ‘Female orgasmic disorder’ is the label attached to a woman whose orgasms are delayed, or who is unable to reach them. Pain disorder involves pain associated with sex, problems also known as dyspareunia or vaginismus. One of the criteria for each of these disorders is that women must be distressed or bothered by their situation in order to qualify for a formal diagnosis from a doctor.
Using these definitions as a foundation, different groups have revised and rewritten their own versions, as researchers struggle to find the words that accurately describe what goes wrong for women sexually. As to the causes of this ‘dysfunction’, the conventional medical view readily acknowledges that psychological and social factors play a big role in sexual difficulties. A woman may, for example, lose interest in sex when she’s grieving the loss of a loved one, or if she’s been sexually assaulted. Couples can also grow apart over time, and it may be difficult to talk about what’s happening in a relationship. But the medical view is also highly interested in what are regarded as possible biological causes: problems with blood flow to the genitals, low testosterone levels or chemical imbalances in a woman’s brain.
Many researchers have been content to work with the existing definitions of the four sub-disorders in the DSM, and to tinker with them occasionally to try to make them more accurate. Some have suggested the need for a major overhaul of the way the condition is defined.7 Others claim FSD and its four sub-orders simply don’t exist as they are defined, and the DSM approach to classifying women’s sexual problems is fundamentally flawed.
Sex therapist and academic Dr Leonore Tiefer and other experts have argued that the definitions in the psychiatrists’ manual are unhelpful because they’re far too narrowly focused on problems relating to ‘function’. They say the definitions fail to place a woman’s sexual problems in the broader context of her life, her relationships, and the wider society and culture in which she lives. The grass-roots campaign Tiefer has helped create, called the New View, has proposed and published an alternative approach, complete with books, a website and an active global list-serve.8
According to the New View definition—written by a group of psychologists, academics and experts in women’s health—women identify their own difficulties, which are defined as ‘discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience’.9 Unlike the definitions in the DSM, this approach puts more emphasis on trying to understand the causes of a woman’s sexual dissatisfaction, and on attempting to prevent them if possible. The differing approaches reflect a longstanding tension in the world of psychiatry and psychotherapy between those more interested in uncovering the root causes of problems, and those with an emphasis on describing and classifying the symptoms. In sharp contrast to the more medical view favoured by drug companies, Leonore Tiefer doesn’t generally see sexual problems as individual dysfunctions that can be fixed with medications—though she and her colleagues are not opposed in principle to the idea of drugs, if safe and effective medicines emerge.
Under the New View’s alternative approach, the causes of women’s sexual difficulties are divided loosely into four categories. The first includes the broad factors at play in a society that impact on sexuality. These are the religious taboos that breed shame about our bodies, the cultures that help create our inhibitions and the economic factors that leave many women exhausted after combining work and family obligations. The second category of causes includes factors relating to partners, including the common mismatch in the level of desire between partners and other relationship difficulties. The third category is when sexual problems arise from psychological issues, like past abuse or depression. The fourth and final category is when sexual difficulties arise from medical causes, like nerves being damaged in surgery, or the harmful sexual side-effects of anti-depressant drugs, which can impair a person’s ability to orgasm. These four categories are not mutually exclusive, and an individual woman’s difficulties may well be caused by a complex interaction of more than one factor. While it rejects the idea of a widespread dysfunction, there is no sense that this approach plays down the distressing or debilitating nature of these problems for some women.
The tune the New View is singing is clearly not music to the ears of drug companies, whose pills can do little to change religious taboos or relationship woes. Portraying a sexual problem as an individual woman’s failure to ‘function’ makes a drug solution much more appealing. A perspective that puts women’s difficulties firmly in the context of their life and loves, their cultures and societies is far less valuable to those trying to promote new medicines.
The debate about what constitutes a normal part of sexual life and what should be classified as a dysfunction is not only a fascinating contemporary fight, it has a long and rich history. Dive back into the murky waters of the nineteenth century Victorian era and you’ll find that homosexuality, masturbation and oral sex were all considered abnormal, deviant and diseased. Unbelievably, it was only in the 1970s that homosexuality was finally removed from the pages of the DSM.
By the start of the twentieth century, many Victorian-era ideas about sexual deviance and disease were under attack. Writers at that time, including Havelock Ellis, are credited with helping to usher in a more modern way of thinking about sex. Unlike influential thinkers in the nineteenth century, Ellis fought against linking everyday behaviours like masturbation to medical conditions. Seen as a champion of tolerance, Ellis was also a great enthusiast. Sex was ‘the chief and central function of life’, he wrote, ‘ever wonderful, ever lovely’.10 Importantly, he also challenged some of the views of his contemporary, Sigmund Freud.
One of Freud’s particularly troubling theories was that women who couldn’t have a ‘vaginal’ orgasm via intercourse were essentially childlike and immature, a gross misunderstanding of female sexuality that would cast a chill shadow over women’s sense of themselves as sexual beings for much of the following century. ‘The leading erotogenic zone in female children is located in the clitoris,’ Freud announced in one of his essays published in 1924. ‘But it appeared to me,’ he wrote a year later, ‘that the elimination of clitoridal sexuality is a necessary precondition for the development of femininity.’11
In contrast, Havelock Ellis argued that the clitoris was central to female sexuality, and he ridiculed Freud’s notion that adult female sexuality was exclusively vaginal. Yet it took at least half a century before these ideas about the centrality of the clitoris became more widely accepted. For many decades of the twentieth century, women were considered to suffer from the psychiatric illness called ‘frigidity’ if they were not able to experience an orgasm vaginally while having intercourse.12
An article published in the influential Journal of the American Medical Association in 1950 pronounced that frigidity was ‘one of the most common problems in gynaecology’. It suggested that up to 75 per cent of women derived little or no pleasure from the ‘sexual act’, which in most cases was because they were suffering with ‘frigidity’.13 Any condition claimed to affect up to 75 per cent of all women should raise alarm bells for us: could this really be an abnormality or malfunction if it is something that affects nearly everyone? Echoing Freud’s theories, the doctors wrote that in girl children ‘the clitoris gives sexual satisfaction, while in the normal adult woman the vagina is supposed to be the principal sexual organ’. According to these theories, if the normal transference of sexual satisfaction from clitoris to vagina didn’t take place, then the woman had ‘frigidity’, the disorder defined as ‘the incapacity of women to have a vaginal orgasm’. Though the term is rarely used today, it seems the ghosts of frigidity may still haunt much current misunderstanding of female sexuality.
By the mid-twentieth century, though, a fresh breeze was beginning to blow into popular sexual understanding, due in part to the famous work of Alfred Kinsey and his colleagues at Indiana University. Based on lengthy face-to-face interviews with more than 10 000 people, Kinsey and his team produced two major works on sexuality, the first book on men and the second on women, published in 1953.14 The findings were explosive for their time, revealing that many men and women engaged in pre-marital sex, extra-marital affairs and—God forbid—homosexuality. While the term ‘frigidity’ was still being widely used to label women, Kinsey didn’t like it at all.
The failure of a female to be aroused or to reach orgasm during coitus [intercourse] is commonly identified in the popular and technical literature as ‘sexual frigidity’. We dislike the term, for it has come to connote either an unwillingness or an incapacity to function sexually. In most circumstances neither of these implications is correct.
Rather than suffering from some supposed psychiatric disorder called frigidity, Kinsey found that most of the women he interviewed masturbated, almost all of them relied primarily on stimulation of the clitoris, and most reached orgasm that way almost all of the time. In other words, most women in his survey were both willing and able to function sexually, despite claims from within the medical profession at the time that up to 75 per cent might suffer from a sexual disorder. Their sexual dissatisfactions clearly had more to do with the way sex was happening for them, including the inadequacy of the stimulation they were receiving from their male partners, than some psychiatric condition. As to Freud’s theory, still widely accepted in the 1950s, that women could transfer the site of sexual satisfaction from the clitoris to the vagina, Kinsey dismissed it as a biological impossibility.
The work of Kinsey was attacked from all sides—not only by those unable to accept the rich variety of human sexual behaviour he uncovered, but also by those accusing him of poor statistical methods and having an unrepresentative sample. Others believed he and his team put too much focus on the physical, rather than the psychological, aspects of sex. Notwithstanding the criticisms, one of the great legacies of Kinsey’s work is his celebration of the wide variation in human sexuality, and his view that imposing uniform standards of what should be considered normal or abnormal performance is not only impractical but also unjust.15
While Kinsey’s work on women was hitting bookshops across the United States, in London in 1953 an English translation of a French work of philosophy was just being published. Simone de Beauvoir’s feminist text, The Second Sex, painted a sad, angry, despairing portrait of women still aspiring to and struggling to achieve full membership of the human race. ‘The female is a female by virtue of a certain lack of qualities,’ de Beauvoir quoted the Greek philosopher Aristotle as saying, ‘so we should regard the female nature as afflicted with a natural defectiveness.’16 There is a disquieting similarity between Aristotle’s description of women as defective and contemporary suggestions that half of all women have a sexual dysfunction.
Simone de Beauvoir’s weighty classic wasn’t all doom and gloom, however. One of the book’s latter chapters imagines a future inhabited by the ‘independent woman’. It excitedly suggests that the ‘free woman is just being born’ and that she must ‘shed her old skin and cut her own new clothes’. Well aware of the extent of women’s dissatisfaction with their sex lives, the French philosopher was hopeful that the growing feminist activism would ultimately bring genuine equality, which might also improve sex. ‘New relations of flesh and sentiment of which we have no conception will arise between the sexes,’ dreamt de Beauvoir.
The French feminist’s dream helped set the scene for the sexual revolution of the 1960s, in which women in many places felt freer to express themselves sexually, and the birth control pill allowed them to do so without fear of pregnancy. However, with genuine equality between the sexes still elusive, the newfound freedom to have sex also had a downside: the expectation that women were now more available for sex, whether they were interested in the idea or not. Theories about sexual difficulties were being developed against the backdrop of the tensions between a growing freedom and a continuing inequality between the sexes. Women might have had more sexual choices, but many were still in unequal relationships, often economically dependent on their male partners, and in some cases staying in abusive relationships because they couldn’t see a way out.
As the 1960s rolled around, changing times and technology meant that much of the next act in the dramatic history of sex research was caught on film. Starting not long after Kinsey’s explosive book on women was published, American medical researchers William Masters and Virginia Johnson began what would become their world-famous laboratory investigations. Their team would ultimately film hundreds of men and women engaged in sexual acts, including intercourse and masturbation. They would document more than 10 000 orgasms, measuring all manner of physiological responses, trying to gain insights into the nature of sex.17 Their work produced detailed descriptions of the major changes in the human body associated with sex, like blood flow to the genitals, vaginal lubrication and nipple hardening, as well as the celebrated phenomenon of the multiple orgasm. Based on their measurements, the pair described a ‘sexual response cycle’ that included the four phases: excitement, plateau, orgasm and resolution. Their observations of the patterns of sexual arousal and orgasm, similar in men and women, played a key role in further developing scientific understanding of sex. They also influenced the controversial definitions of ‘female sexual dysfunction’ that would emerge decades later.
Masters and Johnson also did their bit to shatter myths about sex and older women. ‘Nothing could be further from the truth,’ they observed, ‘than the oft-expressed concept that aging women do not maintain a high level of sexual orientation.’18 While older women experience physical changes like a thinning of the skin of the vaginal walls and a slowing in lubrication, these researchers found no decline in the functioning of the clitoris, which their observations had confirmed as central to the female orgasm.19 In other words, the changing frequency of sexual activity over a woman’s life, or the slowing down that can come during a long relationship, were not necessarily the same as a decline in the capacity to function sexually.
Like Kinsey, Masters and Johnson didn’t like the word ‘frigidity’, and they chose instead to use words considered then to be less judgemental like ‘inadequacy’ or ‘dysfunction’. As for the sources of people’s sexual problems, the couple saw a complex set of causes, including physical or biological factors. But even though they were working within a medical framework, they also emphasised the psychological, social and cultural causes of sexual problems—including forces like religions, responsible for so much guilt and shame. These cultural causes, they said, more often than not placed a woman in a position where ‘she must adapt, sublimate, inhibit or even distort her natural capacity to function sexually’.20
These comments about women ‘inhibiting’ and ‘adapting’ their sexuality foreshadowed debates that would appear much later about how to define women’s sexual troubles. Where drug companies are now trying to portray an individual with low desire as having a disorder to be fixed with pills, others see the normal behaviour of a healthy woman adapting to her surroundings, whether that might be an unhappy relationship, an early experience of abuse, or simply the pressures of trying to juggle the toddlers, the job and a chronic lack of sleep. No one dismisses the pain of a woman distressed by a debilitating lack of desire, or by the damage to her relationship that can come if her partner is saddened or angered by it. The question is how to best describe, understand and deal with it.
Delving into the debates about the causes of sexual difficulties can be both intriguing and frustrating. While one learns a lot about the reasons for dissatisfaction and discontent, it is rarely clear what the best ways to address them might be. Something receiving a lot of public attention at the moment is the decline in desire that can happen at different times during a relationship. It goes without saying that sexual interest waxes and wanes over time, depending on where you are in life, whether you’re single or with a partner, and the point at which you are in a relationship. But this specific challenge of maintaining a healthy and happy sexual life within a long-term relationship has been a key interest of many sex researchers, including Alfred Kinsey. His view was that men and women in relationships tend to want a range of partners and sexual experiences, a point emphasised colourfully in the Hollywood film of his life, Kinsey.
‘Reconciliation of the married individual’s desire for a variety of sexual partners and the maintenance of a stable marriage presents a problem which has not been satisfactorily resolved in our culture,’ says Liam Neeson, the actor playing Kinsey.21 The words are uttered during a presentation given to his peers, moments before he collapses under the combined weight of the attacks being waged on his work and the sheer enormity of the task of trying to understand human sexuality. Half a century later, though the idea of lifelong marriage has faded considerably since the 1950s, the issue of the waxing and waning of desire in a loving relationship remains resolutely unresolved. Couples obviously go through periods of more or less sex, depending on whether they’re relaxing on vacation or straining under the weight of work stresses. However, as Leonore Tiefer argues, the pharmaceutical industry is putting more focus on the waning of sexual interest as a problem, helping to construct the idea that a more constant and consistent level of desire is somehow the norm. ‘It’s sinister and it’s insidious,’ she says.22
Back when William Masters and Virginia Johnson were writing their books, Viagra, the blue pill for boys, wasn’t yet even a twinkle in a marketer’s eye. Back then, sex therapy was seen as one of the main solutions for sexual problems. Masters and Johnson’s influential model of couple therapy, developed at their clinic in St Louis, involved both members of the couple and two therapists working intensively for a matter of weeks. Masters and Johnson claimed that this approach was very effective, though they are known more for their research and publications than for the rigour of their scientific self-assessment, so we’re not really sure how well their sessions worked.
‘It is to be hoped that human sexual inadequacy . . . will be rendered obsolete in the next decade,’ Masters and Johnson wrote optimistically in the opening to a book they published in 1970.23 The hope of successfully battling the species’ sexual inadequacy in the space of a decade is certainly an honourable one, but it seems just a little unrealistic. It is worth reflecting, though, that these sorts of optimistic sentiments about treating, preventing and ultimately eradicating sexual problems are rarely heard any more, with corporations so reliant on selling drugs to people long term. If sexual problems were capable of being done away with via short bursts of intensive therapy, there would be no lucrative markets for the ongoing use of expensive drugs. In the 1970s, though, the pharmaceutical solutions were still some way off.
In 1976 the world’s understanding of female sexuality took another step forward with the publication of The Hite Report.24 Written by the feminist and educator Shere Hite, the report featured many explicit and engaging personal revelations about sexual experiences gathered from hundreds of women. Its key messages included that most woman could most easily reach climax through direct clitoral stimulation, that intercourse alone didn’t generally provide enough to do the job, and that women who were unable to orgasm vaginally were in no way frigid, inadequate or dysfunctional. Like most major works on sexuality, the report has been heavily criticised, not least for its unrepresentative sample; however, its influence is unquestioned. Hite’s book sold millions of copies, was translated into many languages and took pride of place on bookshelves all over the planet.
Needless to say, despite growing sexual awareness, the quaint hope that all our sexual inadequacies would be eradicated by the year 1980 didn’t come to pass. The emphasis on sex therapy and the benefits of counselling as a way of dealing with sexual problems continued, but by the early 1990s a monumental change was coming to the world of sexuality. Researchers testing an experimental heart drug accidentally discovered it could increase blood flow to the genitals, and men’s erections could be improved as a result. Viagra burst on to the scene and the biggest drug company in the world launched one of the most successful marketing campaigns in human history. Advertised at first by an aging politician as a treatment for a medical condition called ‘erectile dysfunction’, suffered predominantly by older men, the marketing of the drug was quickly transformed. In no time, television and magazine advertisements in the United States were portraying Pfizer’s Viagra as a necessary sexual accessory for men of any age. As the marketing slogan told us, the pills could offer powerful performance when you want it.25 A medication morphed into a sex aid, and a new multi-billion dollar market was born. So too were lively debates about the pros and cons of Viagra, credited with rekindling the love affairs of older Americans and criticised for narrowing the global conversation about sexuality to the hardness of a man’s erection.
Viagra didn’t just pump up penises, it also helped bring a new legitimacy to those who studied sexual problems. As the film of Kinsey’s life showed, it wasn’t so long ago that sex researchers were frozen out of the mainstream of science and denied funding by government health authorities. In the late 1980s, leading voices were lamenting the fact that the study of sex was still sorely missing the ‘scientifically respectable apparatus’ of having its own academic departments and professors of sexuality. There were calls to create a rigorous new ‘sexual science’, with sound methods of doing both qualitative and quantitative research using reliable measurement tools.26 With the arrival of Viagra in the 1990s the fortunes of this field turned very rapidly around, as that ‘scientifically respectable apparatus’ began to be constructed. The drug industry soon extended the warm hand of friendship and funding, bringing sex researchers in from the cold and dark and helping them to build a whole new science of what’s becoming known as ‘sexual medicine’.27 For doctors and psychologists working in the area, the new wonder drug was something that would not only help their patients; it might also lift up an entire field of health research.
Even before the drug was officially launched for men, plans were underway to test it in women. The problem was that, unlike men—where success could be measured by the hardness of a man’s penis—it wasn’t exactly clear how to measure sexual pleasure in a woman. Should it be the size of her swelling clitoris, the number of her orgasms or her feelings of sexual arousal? At that point, a decision was made to gather together a small group of researchers who specialised in women’s sexuality, to start getting some answers. It would prove to be an historic gathering.
The quality of the light is one of the things that strike you first about Cape Cod in Massachusetts, in the northeast corner of the United States. It’s as if you can see things more clearly from there. The wildness of the beaches, the sensuality of the sunken meadows and the clean waters of the pristine ponds are a world away from the hustle and bustle of busy Boston and metropolitan America, a couple of hours up the highway. The Cape’s beauty has long attracted artists, travellers and holidaymakers, and in the spring of 1997 it brought together a very important group of doctors, sex researchers and drug company officials. They’d been assembled with the aid of a charismatic psychologist called Ray Rosen.
A tall, handsome man, Dr Rosen is highly regarded for his intelligence and clarity of vision. Friendly and well-connected, Rosen was at the time based at the Robert Wood Johnson Medical School in New Jersey, not far from New York, Pfizer’s home town. In the 1990s, while still testing Viagra, the company had been looking to make wider connections in the academic community, and Rosen would have appeared as a natural fit— particularly with his expertise in designing measurement tools, including questionnaires. Rosen would also have seen benefits in making links with a big pharmaceutical company. Apart from the funding for individual research projects and consultancies, the industry’s money could help raise the profile of the whole area of sex research, ultimately helping men and women with better care. It also presented a chance to get in on the ground floor and work with this revolutionary new approach to treating sexual dysfunction. Drugs were already around that could be injected into the penis to help men’s erections, but Pfizer’s new blue pill worked via a different, far more convenient, mechanism. Soon the New Jersey academic entered into a working relationship with the world’s biggest drug company.
As a psychologist, Ray Rosen was aware of the potential of counselling, and like many of his medical colleagues he shared what is known as a ‘bio-psycho-social’ approach to understanding and treating sexual problems that is both comprehensive and holistic. He was also enthusiastic about the possible role of prescription drugs for both sexes. Given what researchers knew from Masters and Johnson’s observations about the similarities in male and female sexual response, and the important role of genital blood flow in both sexes, it was theoretically possible that Viagra’s benefits for men could apply equally to women. For Rosen and many of his colleagues, new opportunities for both research and treatment were opening up before their eyes, and they would grasp them with enthusiasm and energy.
Before long, it wasn’t just Pfizer in the race: numerous drug companies were looking to develop their own experimental medicines, including the Californian outfit Vivus, which had high hopes its genital cream could sexually arouse millions of women. The industry was looking to make links with ‘thought leaders’ to help guide its drug development and raise awareness of FSD. Like health professionals across all areas of medicine, Ray Rosen embraced the chance to collaborate with industry— as would many others. The sort of the collaboration he had in mind was spelled out very clearly in an email he sent to one of his colleagues around this time, his old friend Leonore Tiefer.
Warm, gregarious and highly eloquent, Tiefer was already something of an identity in this small field, and both she and Rosen had already served terms as office holders of the International Academy of Sex Research. For more than a decade, Tiefer had been working in the urology departments of New York hospitals, interviewing men who were being treated for sexual problems, conducting research and writing. She had soon become concerned that men’s problems were being treated by the specialist urologists in a very mechanical way, and that sexual difficulties were being reduced to the quality of erections, divorced from the context of men’s lives and relationships. In 1986, long before Viagra came along, she had published an article titled ‘In Pursuit of the Perfect Penis’, which sounded early warnings about what she saw as the medical takeover of male sexuality.28
With the arrival of Viagra, and Pfizer’s entry into the field in the 1990s, Tiefer was soon foreseeing a powerful alliance emerging—a medicalisation of sexual difficulties driven by the medical profession and fuelled by pharmaceutical money. Her response to the rivers of funding starting to flow from drug companies was very different from Ray Rosen’s. Her worry was that the small pools of sex researchers were in danger of being inundated by the muddy waters of drug company influence.29 She was concerned that this might contract the focus of research on to the narrow, more physiological aspects of sexuality—like blood flow and hormones—for women as well as men. She’d heard that her old mate Ray Rosen was organising an important gathering on women’s sexuality in Cape Cod, so she’d emailed him asking about the possibility of attending.
Rosen’s reply to the request was blunt. The two were old friends so he felt he could be candid with her. He revealed that the main point of the meeting was to work out how to assess female sexual function in clinical trials involving drugs. In other words, the meeting would focus on how to measure the impacts of experimental drugs like Viagra on women. Perhaps even more importantly, his email revealed that the drug companies would be picking up the tab for the entire Cape Cod affair:
The meeting is completely supported by pharmaceutical companies, and approximately half of the audience will be pharmaceutical representatives. The goal is to foster active and positive collaboration between the two groups. Only investigators who have experience with, or special interest in working collaboratively with the drug industry have been invited, and that’s the obvious reason I had not included you. Your views of the issue are very well known to all.30
Rosen’s email went on to offer Tiefer the chance to attend only if she was ‘willing to genuinely participate’ in the meeting, an offer she ultimately declined after much deliberation, deciding she did not want to be part of this emerging collaboration with industry. Others had no such reservations, and a core of sex experts and drug company officials soon flew into Cape Cod from across the United States and around the world.
That Cape Cod conference marks the dawning of the new era of ‘active and positive’ collaboration between the global pharmaceutical industry and a small group of highly influential sex researchers focused on women’s sexual problems. Discussions at that meeting would help inform a whole new scientific agenda, ultimately sparking new research projects, surveys, questionnaires and educational programs—the very building blocks of the science of this new dysfunction. Most immediately it would lead to more meetings of sex researchers, many of which would be heavily sponsored by industry. The following year, a group of ‘thought leaders’, including Ray Rosen, would meet in Boston in a closed session to revise the definitions of female sexual dysfunction, or FSD. The vast majority of the nineteen ‘thought leaders’ would disclose that they had some sort of relationship with industry.31 As in many areas of medicine, the drug companies weren’t writing the definitions, but the panels of experts who did included many with financial ties to those companies. Typically, those ties could involve being an adviser or consultant, being contracted to do research or being paid for speaking engagements.
That important meeting, at which the definitions were revised, took place just up the road from Cape Cod in Boston, where another of Ray Rosen’s colleagues, Dr Irwin Goldstein, was based. A professor of urology and gynaecology, Irwin Goldstein started his professional life as an engineer before switching to sex research, an area in which he is highly regarded and has become well recognised. A practising doctor and widely published university academic, Goldstein has also retained his boyish good looks along the way. In addition to all his publicly funded research via grants from the National Institutes of Health, Goldstein has worked with many of the world’s biggest drug companies, which he sees as playing a paramount role in helping build the new science of sexual medicine.32
By the start of the twenty-first century, the gatherings of this group of researchers interested in women’s sexual difficulties were becoming annual scientific conferences, now attracting support from more than twenty companies, with Pfizer as a key sponsor.33 And the drug companies weren’t just funding the get-togethers: on some occasions, their staff were actually attending as well, taking part inside the scientific sessions. These were the sorts of activities to which drug company research manager Darby Stephens was referring when she talked of working closely with ‘thought leaders’ to jointly develop this new disease entity. Yet while this close working relationship is the norm in medicine, not all drug company managers are as candid when it comes to describing it.34 An official from Pfizer was far less forthcoming than Darby Stephens when he was interviewed about his company’s activities. The way he told it, the giant corporation was simply playing a ‘passive’ role by providing unrestricted grants for conferences in response to requests from physicians. Importantly, he also referred to FSD as a ‘disease’.35
More recently, Pfizer has described the grants it provides for conferences as part of a much broader process of partnering with medical, scientific and patient organisations, helping to ‘strengthen communities’ and produce a ‘healthier world’. Confirming Irwin Goldstein’s views about industry’s paramount role, the world’s biggest drug giant proudly states that it has conducted and sponsored many scientific studies in the field of FSD, not just testing drugs, but also generating knowledge about the ‘nature of female sexual dysfunction and its impact on women and their partners’.36
The sponsored gatherings at Cape Cod and Boston weren’t only a chance for informal socialising and an opportunity to build friendships between marketing managers and university-based researchers. They were also the places where the new science of sexual medicine was being constructed, the new corporate-sponsored knowledge was being created, and the latest definitions of FSD were being written. These gatherings can be highly influential in the wider world of medicine and among the general public. Deliberations at these meetings are often covered in the media, and later published as important journal articles or guidelines for treatment, which in turn can be carried dutifully to your doctor’s door by friendly drug company sales reps eager to educate the medical profession about the latest disorders. Embedded in a lot of this material is a strong view that common sexual difficulties are best described as medical dysfunctions. The downstream impact of all this on your doctor and the way he or she thinks about the problems in your sex life cannot be overstated.
Within a few short years of the historic meeting in Cape Cod, the drug companies were funding far more than just conferences for sex specialists. They would hand out direct grants to universities to educate medical students about women’s sexual health, fund educational seminars for practising doctors and workshops for healthcare journalists. In the case of Pfizer at least, some of their sales staff would also ply doctors with kickbacks and inducements, according to court documents from an official whistleblower.37 All of this was long before any sex drug had even been approved for women. A key aim was to win widespread acceptance of the idea that a woman’s common sexual difficulties might be the sign of a treatable dysfunction. For many researchers, all this activity was bringing what they regarded as long-overdue recognition to women’s sexual suffering, and legitimacy to its study. For the drug companies, it was a strategic part of the planning for what was being billed as the next billion-dollar market.
A forward-looking business intelligence report in 2003 named FSD drugs as an area of great future growth for the pharmaceutical industry, part of the burgeoning ‘lifestyle’ market including medicines for baldness, smoking cessation and obesity.38 The report was prepared for industry insiders and, with a hefty price tag, was never intended for public consumption. However, a leaked copy described how drug companies were ‘expanding the patient pool’ by using marketing campaigns to change public perceptions about things that used to be considered part of normal life. ‘The medicalisation of many natural processes,’ the report observed, ‘is creating markets for lifestyle drugs for those who want to optimise quality of life.’ It predicted that the market for FSD drugs could soon approach a billion dollars a year. The days when the treatment of sex problems was dominated by the idea that therapy could render sexual inadequacy obsolete were quickly forgotten, swept away in a collective enthusiasm for new panaceas to treat this new dysfunction, and the billions that might flow from it. But the enthusiasm was not universal.
Leonore Tiefer was by now pointing out in her writings that the post-sixties opportunities for the sexual emancipation of women were sadly being squandered in the medical takeover of sex.39 Rather than attaining further freedom, the fear was that women were being subtly encouraged to feel inadequate, or even dysfunctional, if they failed to live up to a new unrealistic norm of a constant desire for sex. Right on cue, the new blue pill bounced straight from the doctor’s surgery to the centre of popular culture. Viagra famously made a cameo appearance in the television series Sex and the City, when Samantha took the drug and apparently enhanced her already considerable sexual enthusiasm.40 Apart from her broader social critique, Tiefer was also busy documenting drug company sponsorship of all the important meetings where the new disorders were being developed. The resulting evidence offered a rare insight into the extraordinary extent of pharmaceutical involvement with an emerging field of medicine.
Informed in part by this evidence, an article in the British Medical Journal (BMJ) described the making of FSD as the ‘freshest, clearest example we have’ of the corporate-sponsored creation of a disease.41 The article caused media reaction around the world, and was heavily criticised by several ‘thought leaders’ in sex research. They felt it played down the genuine suffering of women with legitimate sexual difficulties and set back the aim of finding safe and effective treatments for them.
The BMJ piece also brought a negative response from Shere Hite, author of The Hite Report. She criticised it, but from a very different perspective. For her, it didn’t go anywhere near far enough. Hite claimed that in the race to get a pill to market, the pharmaceutical industry was fundamentally misunderstanding women’s sexuality due to serious flaws in the definitions being used. She argued that the four supposedly distinct disorders of FSD—desire, arousal, orgasm and pain—were in reality not independent of each other. ‘Anticipating pain will kill off desire,’ she wrote in a feisty opinion piece published internationally.42 ‘An arousal pill may be a costly waste of time if the root cause of that lack of arousal is not addressed.’
Hite’s perspective, based on the material collected for her research, is that many difficulties aren’t due to a dysfunction, but rather to the century-old misunderstanding of female sexual pleasure, dating back at least to Freud. A lack of orgasm during intercourse is a ‘crucial and common underlying reason why many women become disenchanted and uninterested in sex’, she argued, pointing out what other research also demonstrates: that many—maybe most—women don’t reach orgasm regularly through intercourse alone. Yet the popularly accepted version of sex is still focused squarely on intercourse as the time when both partners reach the climax of their sexual pleasure. ‘It is not women who need to change, or be made different through drugs, but the drug industry’s outdated notion of how couples should have sex,’ wrote Hite, echoing debates about the site of female sexual pleasure that had been bouncing back and forwards down through the decades of the previous century.
The notion that both partners in a heterosexual relationship can consistently come to climax simply through intercourse will sound awfully old-fashioned to some readers. Certainly many women can and do reach orgasm through intercourse. But since Kinsey, and indeed even before, the early science of sexuality was confirming that, for many women, the clitoris was the site of their orgasm, and that vaginal intercourse alone was not routinely going to bring all women to climax. Yet so much popular culture seemingly hasn’t caught up with the facts. How many sex scenes in highly regarded films still replay an outdated version of love-making based primarily and solely on intercourse? Try to name a few Hollywood blockbusters, or even art-house features, that accurately portray the physical reality of female orgasm. Even in much supposedly sophisticated pornography, according to Hite, clitoral stimulation is used only as a warm-up, and is not portrayed to the point of climax. For her, the dominant form of sex—even in the twenty-first century—is one that still puts male orgasm before female orgasm, reflecting the still subservient position of women in society as a whole: ‘It’s not arousal pills we need, but a whole new kind of physical relations with each other.’
Exposing the uncertainty and debate around whether women’s common sexual problems are best classified as dysfunctions or difficulties is not an attempt to trivialise them. On the contrary, the hope is that doctors will diagnose women, and offer them therapies, only when they really require them, rather than because a powerful drug company that is funding their education wants to see tens of millions of women labelled in order to open the doors to a new mass market. Labelling a woman with a medical condition when she mightn’t actually have one can mean failing to get to the root of her problem—especially if it is not her problem alone but has arisen from her relationship. A wrong diagnosis and potentially unnecessary medications can carry harms and costs for the individual woman involved, as well as for those footing the bill for national health budgets, already straining under the weight of too much medicine.43
Much of the building of the science of this new dysfunction has happened in the light shining out from that 1997 meeting in Cape Cod, where Ray Rosen so successfully helped to bring together the doctors and the drug companies. Another big milestone was laid down less than two years later in 1999, when a landmark article appeared in one of the world’s leading medical journals. The article in the Journal of the American Medical Association reported on the results of a large sex survey.44 It stated baldly that 43 per cent of women suffered from some form of sexual dysfunction, and that this was an important public health concern. As we’ll soon discover, the big figure sparked an even bigger reaction. But here was the next building block in the foundation for the new disease that Darby Stephens and her colleagues and competitors in the industry were rushing to help develop.
