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Introduction Sex, lies and pharmaceuticals

Not tonight, dear, the dog ate my testosterone patch.

—Dr Leonore Tiefer

During the last year or so, has there been a period of several months or more when you lacked interest in having sex? When you felt anxious about your sexual performance or were unable to achieve an orgasm? Was there an extended time when you had trouble getting aroused, experienced pain on intercourse or just didn’t find sex pleasurable? If you answered ‘yes’ to just one of these survey questions, and you’re a woman, you could easily be classified as suffering from a brand new medical condition called ‘female sexual dysfunction’, or FSD. First described in the textbooks only a few decades back, FSD is set to become the next blockbuster medical condition, coming soon to a doctor’s surgery near you. As the ups and downs of daily life are re-categorised as the symptoms of medical diseases, soon all of us will be sick.

One of the women who actually helped write the definitions of female sexual dysfunction puts it very clearly. ‘[W]hat once was considered normal,’ wrote American psychologist Sandra Leiblum, ‘has come to be considered dysfunctional.’¹ Nowadays, if a woman lacks the desire for sex, and is bothered by it, she could be diagnosed with a disorder of low libido. That’s just one of the four main disorders of female sexual dysfunction described in one of the leading manuals of diseases.² The others include disorders of arousal, orgasm and pain. As the evidence plainly shows, forces are fast amassing to tell you, and your doctor, that close to one in every two women suffers from some form of this new medical condition.

The giant pharmaceutical industry—with worldwide sales now approaching a trillion dollars a year—is hungrier than ever for new markets.³ In order to maximise sales, the industry must ‘create the need’ for its newest and most expensive products. Sometimes that means selling sickness to the wealthy healthy, helping transform common ailments into widespread conditions that require treatment with the latest pills.⁴ Applauded for producing medicines that extend life and ameliorate suffering, drug companies no longer simply sell drugs; they increasingly sell the diseases that go with them.

Female sexual dysfunction is perhaps the perfect example of selling sickness, and the commercial firepower behind its forthcoming promotion is simply awe-inspiring. ‘With more than 50 million potential sufferers in the United States, FSD could offer a larger market than male sexual dysfunction,’ wrote a pair of enthusiastic market observers. ‘FSD could be the next boon for pharma companies . . .’⁵ If a drug is approved to treat this condition in the United States, the tsunami of marketing that will be unleashed in the media and on the web will soon swamp the shores of nations everywhere. According to industry reports, one company on the verge of having its product approved for women had set aside $100 million for the drug’s advertising budget alone.⁶

Three global corporations in particular have been at the forefront of the race to spread the word about this new medical condition, and get their drugs approved to treat it. Pfizer, the biggest pharmaceutical company in the world and currently worth well in excess of $100 billion, has had high hopes that its wonder drug for men, Viagra, will also work for women. Procter & Gamble, with global annual sales of almost $80 billion, is famous for selling soap to housewives, but it also wanted to sell them testosterone patches as well.⁷ The third corporation featuring in this drama is the family-owned German outfit Boehringer, which boasts just over forty thousand employees and has affiliated companies in almost 50 countries. The German company’s pill targets the brain, with claims it can give women back their lost desire.

So what exactly is this condition called FSD? The answer depends a little on the solutions being sold at the time you ask the question. If Pfizer is promoting a drug that enhances blood flow to the genitals, then the condition might best be described as an ‘insufficiency’ of vaginal engorgement. If Procter & Gamble is pushing its testosterone patch as a cure for women, the sexual disorder is discussed as a ‘deficiency’ of hormones. And if Boehringer has a pill that affects the mind’s neurotransmitters, women with low libido may have a ‘chemical imbalance’ in their brains. In a strange way, the disease seems designed to fit the drug.

That’s not to say that medicines don’t have a role to play in treating some sexual problems. There are women for whom a medical label and a medication may be extremely valuable. The problem is that when the drug company-sponsored tsunami of marketing reaches its full fury in your corner of the planet, women’s common sexual difficulties will likely be portrayed not as aspects of normal sexuality, but as the symptoms of medical conditions that are widespread and treatable with pills. The fact that sexual difficulties are often caused by a raft of complex factors, from relationship stresses to religious taboos, may well be washed away in the coming flood of pharma-funded magazine features, celebrity interviews on breakfast TV and plain-talking advice from sexy bloggers. The first unmistakeable signs of this marketing are already appearing. ‘What is female sexual dysfunction?’ asks one online personality known as Katie, on her educational website. ‘This health problem is a genuine problem that needs medical attention. Most women suffer from this problem without actually realising it.’⁸

Yet even before the king tide of corporate marketing has really begun to flow, a backlash has been brewing. Working out of her small home office in Manhattan, not too far from the headquarters of the world’s biggest drug giant, a smart feminist scholar has launched a pre-emptive strike. Together with a small group of colleagues, sex therapist and New York University associate professor Dr Leonore Tiefer has started a grass-roots campaign. The fight is against what Dr Tiefer and her colleagues see as Big Pharma’s attempt to help turn the ordinary ups and downs of women’s sex lives into medical diseases in order to sell them drugs. Instead of a medical dysfunction with four neat sub-disorders, the campaigners are proposing a radically different approach to understanding women’s sexual difficulties. As we’ll learn, during the extended combat there have been many colourful skirmishes, like the time Leonore Tiefer won a major award from her peers in the sex research community and delivered a speech titled ‘Not Tonight, Dear, the Dog Ate My Testosterone Patch’.

Pushed for a public response to the criticisms, the powerful pharmaceutical industry has been uncharacteristically shy, rejecting the idea that it creates diseases and arguing simply that it is sponsoring a legitimate field of medical science. For their part, the doctors and psychologists who work closely with the industry believe they’re raising awareness of the under-recognised suffering of women with a genuine sexual dysfunction. More importantly, they say, they’re helping to give those women access to much-needed treatments.

The broader context for this extraordinary fight over female sexuality has been the paradox, in Western countries at least, of an increasing sexual openness accompanied by what appears to be a growing sexual anxiety. The promise of sexual emancipation in the heyday of the 1960s has been followed in subsequent decades by a rising tide of sexual uncertainty. Sex and the City’s Samantha may well climax more often than many of the female characters who came before her, but she lives in a world where pornography has moved from being a subterranean undercurrent to front and centre in the mainstream of advertising and culture. Males may, on the whole, be more sensitive now than they were in the 1950s, but post-Viagra they’re bombarded by marketing messages telling them real men must be eternally ready for action. Confident female media stars provide powerful new models for teenage girls, yet the unhealthy sexualisation of girl children has become a major scandal. Young women might be winning more often in the classroom, but in the bedroom many are expected to remove their pubic hair as a prerequisite for successful sexual activity. And with the popular Brazilian waxing exposing all, cosmetic surgeons are promoting a nip and tuck to tidy up the labia, while online companies offer a genital colorant that ‘restores the pink back to a woman’s genitals’.⁹

When they land, the seeds of the corporate-backed campaign to transform common sexual difficulties into medical conditions will fall on the fertile ground of considerable female insecurity. Yet backward-looking moral panic about a permissive society may not be a helpful response. Perhaps it would be better to confront the reality of women’s sexual dissatisfactions head on, tease out the cultural processes exacerbating their vulnerabilities, and identify the commercial forces seeking to exploit them. The dramatic story documented in Sex, Lies and Pharmaceuticals calls for a much greater scepticism towards simplistic claims that women’s sexual difficulties are somehow due to chemical deficits rather than a complicated set of causes, including the way we relate to each other, our cultures, and our individual and collective histories. With much attention to detail, this book seeks to enable you to make your own decisions about whether to accept the labels your doctor might soon offer you, or reject them if they’re not needed by viewing them as the latest products brought to you by one of the most sophisticated and profitable marketing machines on the planet.

So what exactly is all this marketing, and what form will it take? In some ways, the answer depends on where you are in the world. In the United States, drug company television advertisements will likely be the most popular way of telling people about the new disorders of sexual desire. In other places, the public face of this promotion will take a more subtle form, like an interview with an academic discussing his latest survey of sexual dysfunction. Behind the scenes, however, the drug companies are already helping to build the scientific foundations of this big new condition. As we’ll discover, experts with financial ties to drug companies have been conducting sponsored surveys, designing diagnostic tools and educating your local doctor about this ‘widespread’ condition. And when you look closely at the small print in the disclosure sections of a plethora of medical journal articles about FSD, you’ll find something even more extraordinary. Drug companies are no longer just passively funding these important milestones in the making of a new disease; in some cases, their employees are actively engaged in constructing the basic building blocks of this whole new field of medicine.

Fundamental to the building of this new science are the special relationships between the drug companies and the leading researchers. These are the respected doctors and esteemed psychologists who’ve actually helped revise the medical definitions of female sexual dysfunction and its four disorders. When one distinguished group of researchers sat down to refine the definitions of FSD, 95 per cent of them had financial relationships with the drug companies hoping to develop drugs for the very same condition.¹⁰ The conflicts of interest for this group were clear. As they met to work out what could best be described as normal female sexuality, and what might better be labelled as a dysfunction, many of them had been taking money or receiving other support from companies with an interest in seeing the boundaries of this new condition broadened as widely as possible. In the end, that group chose to define FSD as arising from biological, psychological and interpersonal causes, and claimed it was ‘highly prevalent’, potentially affecting ‘20% to 50% of women’.

Once you have a workable definition of a new dysfunction, you need the surveys to confirm just how widespread it is among the general population. Commonly, that has meant asking women how often they experience things like lacking interest in sex or having trouble getting aroused. By simply ticking the box that says ‘yes’ in these surveys, a woman can be classified as having a condition—even though she may not even see herself as having a sexual difficulty, far less a medical dysfunction. The totals of all those little ticks in the ‘yes’ box are then presented as evidence of alarmingly high rates of women suffering, and scientific proof for a new epidemic. The survey findings will then be followed by the inevitable claims of a massive ‘unmet need’ for new treatments, including the drugs made by the company that might happen to have sponsored the survey in the first place.

The next building block to be laid into the scientific foundations of this new dysfunction is the toolkit that doctors need to measure women’s pleasure and diagnose their sexual disorders. Health professionals are increasingly poking and probing women in their most intimate spaces, in the research labs and commercial clinics out on the new frontier of what’s called ‘sexual medicine’. With ultrasounds, doctors have been measuring the flow of blood to a woman’s clitoris; with blood tests, they’re assessing the levels of her testosterone; and with high-tech imaging machines, they are trying to track the reactions in her brain. At the same time, a battery of new questionnaires is being created to gauge a woman’s sexual success. Yet, while the results of all these tests can appear to offer a woman objective evidence of her sexual dysfunction, there are serious questions about how useful many of the test findings really are. If a potentially dangerous drug improves your desire scores by a few points on a company-funded scale, is it really that meaningful? The facts are stark and incontestable: drug companies have started to help design the very tools used to diagnose these new disorders in your doctor’s surgery. Those same tools could then provide millions of women with a medical label, opening the door to widespread prescribing of the sponsor’s drug.

Next comes the ‘education’, during which your family physician learns about the latest definitions, the survey findings and the new diagnostic tools at company-sponsored seminars featuring company-sponsored speakers. From universities in the American Midwest to prestigious international meetings in Paris, drug company money is providing the platform for much of what our health professionals see and hear about women’s sexual problems. In a fundamental way, corporations driven solely to maximise their drug sales are helping to shape the science of the new sexual disorders, even before their drugs are approved to treat them. The company executives are not actually writing the technical definitions of female sexual dysfunction, but they are bankrolling its creation as a looming twenty-first-century epidemic. This merging of marketing and medical science is not a conspiracy; it’s all entirely legal. And for the time being at least, it’s also perfectly acceptable under the self-regulatory codes of conduct governing the behaviour of scientists, doctors and drug companies. Many might think it’s unhealthy, but with pharmaceutical companies still funding medical associations, patient advocacy groups and even universities, change may be some time coming.

This emerging field of sexual medicine is, after all, no different from almost every other corner of the medical establishment, which—as many of us are already aware—is entangled in a vast web of financial relationships with the drug or device makers. It is important to remember, though, that just because a doctor works as a consultant or speaker for a company doesn’t mean he or she becomes a paid stooge for the sponsor, or conducts lesser quality science. This is not a case of individual professionals somehow changing what they say or do because they’re being paid for specific pieces of work by industry. Usually doctors and drug companies choose to collaborate as partners because of their shared enthusiasm for finding new treatments. The relationships are mutually beneficial, with the companies in need of the doctors’ expertise and credibility as much as the doctors are in need of the industry’s research funding or consultancy fees.

Still, as a result of all these collaborations, in the broad church of differing scientific opinions, people with particular perspectives are provided with influential platforms. Certain voices are amplified through company press releases and medical journal articles, via prominent presentations at scientific conferences and educational seminars, and through the hundreds of millions that may soon be spent on drug company advertisements for new medicines. The cumulative effect, according to the people who study these relationships, may well be a systemic pro-drug bias in contemporary medical science and a gross distortion in the wider public debate about sex.

The other obvious problem is that the patient is too often left out of this picture. Too often the worlds of our leading medical experts are lubricated with drug company largesse, the friendly marketing staff constantly picking up the tab for the doctor’s food, wine, travel and accommodation. Far too frequently, the scientific debates about how to understand and treat sexual problems are taking place in restaurants or lecture halls sponsored by those with a financial interest in widening the reach of a condition, and narrowing the range of solutions offered to treat it.

Apart from sponsoring many of the surveys, questionnaires, seminars and conferences, the drug companies have also been doing a lot of old-fashioned drug testing. They’ve been trial-ling different sorts of medicines to try and fix women’s sexual problems: trying to get more blood flowing to the genitals, boosting testosterone levels or correcting those so-called chemical imbalances in the brain. A slow trawl through the medical literature reveals the industry has been busy funding many studies, including full-scale placebo-controlled trials enrolling thousands of women around the world. But by and large, the much-anticipated female aphrodisiac seems to have remained an elusive fantasy.

The industry has bumped up against an unexpected enemy, surprisingly enough in the shape of one of its own pills. The humble placebo, or dummy pill, appears to be holding its own in the company-funded drug trials, causing great consternation in the corridors of medical power. It turns out that for a lot of women said to suffer with sexual dysfunction, a dummy pill may be just as good as the company’s drug in helping bring modest improvements to their sex lives. The plans being hatched to finally beat that placebo once and for all are yet another fascinating thread in the story of the making of this new medical condition.

The placebo, though, is not the only problem facing those who want to portray common sexual difficulties as sexual disorders. The campaign kicked off by Leonore Tiefer and her feminist colleagues has quickly gained traction around the world, scoring high-profile media coverage of its own, running education programs for health professionals, and winning influential friends among the mainstream of the sex research community. What started as guerrilla warfare has become a full-blown battle over how we understand and deal with what is going wrong in our bedrooms.

Being sceptical about marketing messages, though, doesn’t mean ignoring sexual problems that might benefit from being addressed. Pain associated with sex, for example, is common and can be extremely troubling. As many women already know all too well, seeking help for such problems—also known as dyspareunia or vaginismus—can prove extremely challenging, because in some places there is such poor understanding of the causes and potential solutions. Sadly, much of the recent high-profile scientific activity sponsored by the drug industry appears to focus more on problems of desire and arousal, with the expectation that these complaints might be more amenable to drug treatment.

In a sense Sex, Lies and Pharmaceuticals is less about the sex and more about the lies and pharmaceuticals: the the fictional narratives that flow from the marketing in all its visible and hidden forms. The big picture in this story will reveal how the industry is helping to manufacture new norms and market sexual disorders, trying to create a climate where drug solutions to sexual problems are frequently sought. It will offer evidence to support what others have so astutely observed: that the goal of much modern marketing is not only ‘to make people dissatisfied with what they have, but also with who they are’.¹¹ And it will show how a small grass-roots campaign is exposing and challenging that process. It’s a picture projected on to a giant global canvas, but it will also illuminate the most intimate spaces of our lives for both women and men. As we uncover the details of this captivating conflict, we can’t help but reflect on our own sexual situations—the delights and uncertainty, the pleasures and pain. As Simone de Beauvoir wrote half a century ago in her feminist classic The Second Sex, ‘in sexuality will always be materialised the tension, the anguish, the joy, the frustration, and the triumph of existence’.¹²

Sex, Lies and Pharmaceuticals makes no assumptions about the sexuality of its readers. It assumes instead the infinite variation that is the reality and the beauty of human sexuality. While most of us live with partners, many of us live alone and a significant minority of us are now single. Most of us are attracted to the opposite sex, though many of us aren’t, and for others sex is simply not on the agenda. Some of us are enjoying regular lovemaking with a new partner, while others among us find joy in an occasional encounter during a long-term loving relationship. As a work of investigative journalism, the book offers compelling insights into the making of this particular condition. But once you identify the common patterns of disease promotion here, you’ll see the strategies appearing more and more often elsewhere with other conditions, as the boundaries of treatable illness are inexorably widened. It is important to note that this book does not assume we are passive victims of that promotion or the many other powerful forces at work within our cultures. On the contrary, the detail in the pages that follow is designed deliberately to inform and empower its reader in the face of a coming corporate onslaught.

One of the benefits of drilling into all this detail about sexual disorders is that when you get up close, the very foundations of the conditions start to look decidedly shaky. Similarly, a close reading of the current medical literature reveals that tolerance of the entanglement between doctors and drug companies is waning within the ranks of the scientific establishment itself. Unease about the blurring of medicine and marketing appears to be growing steadily. High-profile reports are finding that the web of financial ties with industry can bring the risk of ‘undue influence’ on doctors’ decisions, potentially jeopardising the care of their patients, the integrity of scientific studies and the objectivity of medical education.¹³ As Sex, Lies and Pharmaceuticals goes to print, there are calls for a major clean-up coming from senior figures within the worlds of politics and medicine. But let’s not get ahead of ourselves. Let’s start the story at the point when excitement about the next billion-dollar disease was first beginning to build.