‘Female Sexual Dysfunction’ in the 21st century:
Different ‘problems’, new drugs, more pressures
Annie Potts
School of Culture, Literature and Society
University of Canterbury
Private Bag 4800
Christchurch
Aotearoa New Zealand
Email: annie.potts@canterbury.ac.nz
Abstract: While the construction of women’s sexualized bodies as aberrant has a
long history in western culture, in the 21st century we are witnessing the increasing
influence of the biomedical model on conceptualizations of normal and abnormal
sexuality and ‘sexual response’. Female Sexual Dysfunction (FSD) has emerged from
biomedicine as a new term that more or less repackages old ‘problems’ such as
frigidity, nymphomania and hysteria in its construction of desire, arousal and
orgasmic disorders. In line with the biomedical model’s propensity to view sexual
difficulties as either having organic foundations, or at least the ability to be treated by
physical means, pharmacological preparations are increasingly considered first-choice
‘quick fix’ interventions on the road to ‘recovery’ from sexual problems. The race is
on to develop so-called ‘pink Viagra’, drugs for the treatment of women’s sexual
difficulties that will be as lucrative as Viagra has been in the treatment of men’s
erectile difficulties. This paper examines the two main factions involved in the current
debate around the increasing biomedicalization of women’s sexuality: urologists and
psychiatrists associated with the Boston Forums on FSD; and feminist activists and
social scientists associated with the New View anti-medicalization campaign. It also
analyzes women’s own responses to biomedicalized accounts of sexuality and the
anticipated advent of sexuopharmaceuticals for women, including perceived problems
(new pressures and demands) as well as potential benefits.
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Introduction
“Pfizer, the drug company behind Viagra is preparing to launch the first
‘orgasm pill’ for women next year. Unlike Viagra, which is blue, the new pills for
women will be pink” (Sunday Times, 27 January, 2004).
Women’s sexuality in western culture has historically been constructed as
problematic (Tuana, 1993), and women’s bodies continue to be “a site of struggle for
definition and control” (Braun & Wilkinson, 2001, p. 17). The contemporary debate
around women’s sexual problems – their causes and remedies – centres on the
increasing influence of the biomedical model of sexuality, and provides the latest
example of such a struggle for meaning and control.
This paper examines the key contributors and perspectives in this debate:
those who endorse biophysiological bases of sexual difficulties and promote the use
of new sexuopharmaceuticals for the treatment of ‘Female Sexual Dysfunction’
(FSD); and those who oppose the expanding influence of biomedicine in everyday
life, arguing sexuality is a complex phenomenon irreducible to mere physical
processes and responses.
To place the debate in context, this essay will first provide an overview of the
medical model of sexuality, including a critical analysis of the centrality of the human
sexual response cycle to this paradigm’s conceptions of ‘functionality’ and
‘dysfunctionality’. Next, the recent push by the medical establishment to redefine
women’s sexual difficulties (in terms of recognized biophysical disorders) will be
explored, particularly in light of the advent of sexuopharmaceuticals such as Viagra
for the treatment of ‘Erectile Dysfunction’ in men, and the ensuing impetus to
‘discover’ similarly effective (and highly profitable) drugs targeting women.
Contesting the authoritative medical model of FSD and its advocates are those
associated with the political campaign for a New View of Women’s Sexual Problems.
Members of the New View group actively oppose the biomedicalized
commercialization of women’s sexuality associated with the pharmaceutical
industry’s growing influence on conceptualizations of health and illness (‘normality’
and ‘abnormality’). The New View’s counter-model for understanding and assisting
women with sexual difficulties will be discussed.
2
Following analysis of the two main sides of this debate (the proponents and
opponents of FSD), the essay moves to engage with the perspectives and experiences
of women themselves in relation to the medical model of sexual dysfunction and the
development of so-called ‘pink Viagra’.1 It concludes with a discussion of the
possibilities for new norms, expectations, pressures and demands to be produced as a
result of the biomedicalization of women’s sexual concerns.
20th century sexual medicine: Human sexual response and ‘dysfunctional’ sex
The medical model of sexuality, which gained authority post-1960s,
subscribes to a mechanistic view of the body, in which ‘sexual response’ is broken
down to a series of consecutive stages as part of a supposedly universal ‘human
sexual response cycle’ (HSRC). This cycle, considered to be a biological given, is
assumed to operate within individuals regardless of cultural or historical factors
(Tiefer, 2001), although it is more or less acknowledged that its usual trajectory may
be compromised by such influences. The pioneers of the HSRC, William Masters and
Virginia Johnson (1966, 1970) posit that men and women respond sexually in a
similar manner, which they reduce to physiological changes associated with
vasocongestion and muscular tension. For example, in the excitement phase of the
HSRC, penile erection is considered neurophysiologically parallel to vaginal
lubrication (Segal, 1994).
Deviation from the ‘normal’ sexual response cycle constitutes a ‘sexual
dysfunction’ in medical discourse, and is understood to manifest through various
symptoms. For example, the American Psychiatric Association’s 4th edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM) determines sexual
dysfunction as “a disturbance in the processes that characterize the sexual response
cycle or by pain associated with sexual intercourse” (APA, 1994, p. 493). The original
form of this cycle consisted of excitement, plateau, orgasm and resolution phases
(Masters & Johnson, 1966); however, a triphasic version is currently deployed by the
DSM IV, comprising desire, arousal and orgasmic phases: these phases correspond
with ‘disorders of desire’, ‘disorders of arousal (and orgasm)’ and pain disorders
(Nicholi, 1999).
During the first part of the 20th century, the medical discipline of psychiatry
assumed responsibility for classifying sexual abnormalities (which were listed as
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‘sexual deviations’ in the earliest diagnostic manuals); however, the ‘discovery’ of the
HSRC was readily accepted by medical professionals due to its reduction of sexual
response to physiological goals. This had a profound impact on subsequent
classifications of sexual difficulties, with the DSM expanding its sexuality section by
nineteen pages in 1980, dividing sexual problems into psychosexual disorders
(including disorders of sexual identity and the paraphilias) and the psychosexual
dysfunctions (which represented inhibitions in any of the four phases of the normal
HSRC). The most recent edition, the DSM IV, omits the prefix ‘psycho’ from
‘psychosexual’ (APA, 1994), a consequence of the growing inclination to view
sexuality mainly as a biological construct (Potts, 2002).
Masters and Johnson’s original model of the HSRC has attracted strong
criticism. Feminist scholars have disputed its androcentric bias (female sexuality is
assumed to follow the observed ‘normal’ trajectory of male sexuality), universalist
claims (one cycle fits all), and reductionism (it diminishes sexual pleasure to
physiological responses, women’s and men’s bodies to genitalia, normal sexual
practice to heterosexual intercourse, and ‘healthy’ sexual response to orgasm) (Tiefer,
1995; Potts, 2002). The various sexual dysfunctions constructed according to the
stages of the HSRC are similarly censured. Moreover, the HSRC assumes some sort
of sexuality is necessary and healthy for everyone; there is no space for someone who
is not sexual, who does not care for genital contact, or who is not interested in sex per
se to be viewed as healthy or normal (Potts, 2002).
21st century biomedicalization and sexuopharmacology
Ideas about normal sexual response – and functional/dysfunctional sex –
filtered into popular culture and everyday talk in the latter half of the 20th century,
forged by their association with the authoritative medical model. Medical
constructions of normal and abnormal sexuality now impact on women’s own
understandings and experiences of sexual pleasure in profound ways (Potts, 2002).
The term medicalization refers to the process whereby “diverse areas of human
behaviour are brought within a medical frame of discourse both conceptually and
institutionally” (Tiefer, 2001, p. 65). One consequence of the medicalization of
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sexuality involves the framing of women’s sexual concerns as primarily physiological
based, and hence able to be treated by physical means.
Since the advent of Viagra - following its approval by the US Food and Drug
Administration for the treatment of erectile difficulties in 1998 - there has been a turn
to examining what is termed biomedicalization. Clarke et al (2003) argue that the
process of biomedicalization marks a new transformation in medicine, whereby
medicalization is “extended and reconstituted through the new social forms of highly
technoscientific biomedicine” (p. 161). Significantly, the process of biomedicalization
is intimately linked to the world of late capitalism, and especially the pharmaceutical
industry (referred to by critics as Big Pharma) (Moynihan & Cassels, 2005; Tiefer,
2004; Loe, 2004; Healy, 2004; Elliot, 2003; Metzl, 2003). Clarke et al (2003) contend
there has been a shift from normalization of bodies - achieved through the process of
medicalization - to customization (tailor-made drugs, niche marketing and ‘boutique
medicine’), associated with biomedicalization and with the pharmaceutical industry’s
concentration on so-called life-style drugs, medications that improve or enhance one’s
life but that may not address any actual disease process: “Viagra exemplifies this
movement towards enhancement and the concern with ‘treating’ the signs of aging”
(p. 181).
The expanding influence of the biomedical model is demonstrated in the shift
over the past 5-10 years to viewing women’s sexual problems as more likely to be
physically derived (rooted in the body, rather than psychologically, emotionally or
relationally based), and therefore more readily addressed through organic solutions
such as medications. For example, in his examination of the content of four key
academic sexuality journals over the period 1967-2000, Mark Winton (2001)
identified a marked transfer from psychological to biophysiological explanations for
women’s sexual difficulties - particularly arousal and orgasmic ‘disorders’ - occurring
between 1999 and 2000. Another trend connected to the increasing biomedicalization
of women’s sexual problems is the promotion of FSD by urologists; this is a relatively
new phenomenon, and one which Hartley and Tiefer (2003) connect with a desire on
the part of urologists to move the classification system for sexual problems from the
arena of mental health (in the DSM) into the field of physical medicine (a change
which would also assist the promotion of physical remedies for sexual complaints).
5
The contemporary dispute around definitions, classifications and treatments
related to ‘Female Sexual Dysfunction’ foregrounds this relationship between the
medical establishment and Big Pharma: on one side, urologists, psychiatrists and
sexologists, supported financially by drug companies, endorse the biophysiological
nature of FSD, and the use of pharmacological remedies; on the other side, critics of
the biomedical model protest against this reductionist framing of sexuality, and
expose the insidious influence of Big Pharma in our everyday lives. Critics of
biomedicalization argue that the ‘cure’, in the form of freshly developed (and
potentially highly profitable) drugs, tends to precede and determine the illness or
condition (that is, the nature of new diagnostic categories). Drug companies
manufacture their own markets through defining everyday ailments as pathological,
and then supplying remedies for these newly recognized diseases (Healy, 2004;
Metzl, 2003). Canadian sociologist Barbara Marshall, who represents the antimedicalization position, comments in relation to the investment of Big Pharma in
women’s sexual well-being:
.
It appears more and more like research on female sexual dysfunction is
directed at ‘discovering’ the problem for which lucrative remedies already
exist. As with the expansion of the disease-model of erectile dysfunction to
reflect the success of the available therapy, there is no simple linear move
from an objectively defined disease state to ‘discovery’ of a cure – rather the
‘cure’ often appears to define the ‘disorder’ (Marshall, 2002, p. 142)
The following section unravels the various positions and issues associated
with the contested domain of women’s sexual problems.
The FSD debate
Proponents of biomedicalization: The Consensus Committee
“I view female sexual dysfunction as a potential explosion for the field of female
urology … We think [diminished blood flow to the vagina] is equivalent to
vasculogenic impotence in men” (Goldstein, quoted in Bankhead, 1997, p. 39).
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The biomedicalization of women’s sexual difficulties at the turn of the 21st
century can be traced through several important events and publications sponsored in
the main by drug companies and taking place in the period 1997 to date (Moynihan,
2003; Treacher, 2003, Loe, 2004, Tiefer, 2004).
Shortly after the advent of Viagra for men, there was a flurry of activity to
identify similarly ‘effective’ and profitable drugs that might work for women. First,
however, there were several obstacles to overcome in the race to manufacture a pink
Viagra. For example, since identification and classification are the cornerstones of the
medical model (Hartley & Tiefer, 2003), exactly what problem(s) or condition(s)
would this drug treat? And, given the long history of constructing women’s sexuality
as mysterious, complex and contentious, how might a drug like Viagra be assumed to
work for women in the same straight-forward manner it appeared to work for men?
(Fishman, 2002). How would any drug’s impact on women be measured in easily
quantifiable terms befitting the medical model (that is, in the way a ‘restored’ erection
had counted for successful treatment of erectile difficulties in men)? (Tiefer, 2003).
Thus, a party of 19 leading international sexuality researchers and clinicians,
18 of whom had financial links to pharmaceutical companies (Moynihan, 2003), came
together under the rubric of The Consensus Committee on FSD, in order to revise the
DSM IV’s existing nomenclature on sexual difficulties affecting women, a task
accomplished by providing revamped norms of female sexual response, and clearer
definitions of dysfunction. Alongside the establishment of this committee, annual
meetings have occurred foregrounding biomedical perspectives on FSD (known as the
Boston Forums), hosted by Boston University School of Medicine’s Department of
Urology. The first Forum in October 1999, titled “New Perspectives in the
Management of Female Sexual Dysfunction”, was attended by four groups of
‘players’: experts on FSD (clinicians, scientists), marketers (pharmaceutical company
representatives), critics, and journalists (Loe, 2004). Following the 1999 Boston
Forum, a new organization was established, called the Female Sexual Function Forum
(FSFF).
The ‘need’ for such a forum on FSD was asserted on the basis of a study
published in February 1999 in the Journal of the American Medical Association (and
authored by consultants to Pfizer, the company manufacturing Viagra) (Hartley &
Tiefer, 2003), which claimed that sexual dysfunction affected 43% of women in
America (Laumann et al, 1999). This statistic is now routinely employed in drug
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company advertising, despite the fact that the authors of this study have since argued
their figures did not equate with clinical diagnosis and they were not suggesting 43%
of women actually experienced FSD (Moynihan & Cassels, 2005).
The biomedical faction is represented by several prominent urologists,
psychiatrists, gynaecologists and sexologists (see Basson et al, 2003). Foremost is
Irwin Goldstein, urologist and specialist in ‘erectile function’, who has produced
numerous articles asserting the significance of organic aetiology in sexual difficulties
(and is notable for his perspective that sex is basically a mechanical event, albeit one
that is more complicated for women). In an interview with HQ magazine, he reported
that clitoral erections “are crucial for the maintenance of [women’s] sexual health”
(cited in Hitt, 2000, p. 98). Goldstein’s position is supported by ‘the Berman sisters’
(as they are popularly known), urologist Jennifer and sex therapist Laura, a duo who
have achieved celebrity status as the front-people promoting FSD through
appearances on the Oprah Winfrey Show (in 2001) and numerous current affairs
programmes, via articles in various magazines, and through the publication of their
own book (targeting a general audience) called For Women Only: A Revolutionary
Guide To Overcoming Sexual Dysfunction And Reclaiming Your Sex Life (Berman &
Berman, 2001). The Berman sisters contend that in the majority of cases, an organic
disorder precedes an emotional one, and are outspoken advocates of allocating drugs
such as Viagra to women off-label.
The key changes to the medical categorization of women’s sexual difficulties
resulting from the Boston meetings (and presented in a document called ‘ConsensusBased Classification of Female Sexual Dysfunction’) included expanding existing
nomenclature, adding a clause to each category regarding ‘personal distress’, and
amending diagnostic criteria in order for physical treatments to be more acceptable for
the treatment of FSD of unknown or psychological aetiology (Treacher, 2003). In the
1994 version of the DSM IV, female sexual disorders are classified under the
following headings: Hypoactive Sexual Desire Disorder (HSDD), Female Sexual
Arousal Disorder (FSAD), Female Orgasmic Disorder (FOD), and the pain disorders
(such as dyspareunia). The proposed revised classifications of FSD consist of
expanded versions of FSAD to include 4 different types (Combined Sexual Arousal
Disorder, Subjective Sexual Arousal Disorder, Genital Arousal Disorder and
Persistent Arousal Disorder), and the addition of two new disorders (Persistent
Arousal Disorder and Non-Coital Sexual Pain Disorder). The new classification
8
system – in an arguably progressive move - also stresses that a sexual disorder is
determined according to subjective (personal) experience and distress; that is, a
person should not be labelled dysfunctional if they do not agree there is a problem.
In the bevy of publications related to the so-called consensus-based
categorizations of FSD, the authors claim to have paid attention to the concerns of
feminists and other critics regarding earlier classification systems which failed to take
into account contextual, relational and gender factors (Basson, 2000; Basson, 2001;
Basson et al, 2003; Basson, 2004a & b; Basson, 2005; Sugrue & Whipple, 2001). In
order to address criticism of the masculinist assumptions of previous models of the
HSRC, several versions of the female sexual response cycle have been proposed. For
example, Rosemary Basson (2001) suggests women’s sexual response follows
different trajectories; one version she describes shows arousal occurring prior to
desire, a response she claims is usual to many women but which, according to Masters
and Johnson’s depiction of the HSRC, would be diagnosed as dysfunctional.
The biomedical model of women’s sexuality subscribes to two key positions.
Firstly, ‘the body’ is treated as the problem (or at least any problem can be treated
through the body), thus the experts in FSD focus primarily on the biophysiology of
sexuality (poor circulation and/or deficient or overly abundant amounts of certain
hormones are blamed for insufficient or excessive stimulation or arousal) (Loe, 2004).
Because the body is positioned as problematic in this framing, ‘management’ of these
new conditions also increasingly favours the use of medications. The growing
importance placed on biophysiological aspects of sexuality is demonstrated in
changing patterns of research and treatment regimes from 1998- 2004, the period of
the Boston meetings. Goldstein’s report on the first consensus meeting regarding FSD
recommended clinical trials of drugs alongside efficacy studies of psychotherapy for
sexual difficulties; three years later, the terrain shifted to a focus only on
pharmacological interventions (usually off-label) with drugs such as androgens,
oestrogens, and dopamine agonists for the sexual desire disorders, prostaglandins for
Genital Arousal Disorder, Selective Serotonin Reuptake Inhibitors (SSRIs) for
Persistent Sexual Arousal Disorder, and tricyclic antidepressants for dyspareunia (see
Basson, 2004, 2005).
Secondly, the biomedical model assumes that women’s sexuality is more
complex and difficult than men’s. FSD meetings over the past 5 years have
consistently employed the model of a complex-looking mechanical contraption,
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bearing numerous buttons and switches, to represent women’s sexuality; while at the
same time men’s supposedly straight-forward sexual response is portrayed through a
similar machine sporting just one on/off switch (Fishman, 2002). Of course, this
representation continues the tradition of viewing women’s sexualized bodies as
mysterious, aberrant, and unpredictable, requiring more control or management
(Tiefer, 2003).
Dissent from within the medical model: While the new classifications of FSD
devised by the Consensus Committee received backing from many experts in the
fields of sexual science and medicine, dissenters also emerged from within the
medical establishment. These figures do not necessarily reject the idea of organic
influences on sexual problems, but they argue that the causes of women’s sexual
concerns extend beyond the body, and are as much – if not more - located in lifestyle,
partnerships and relationships, and other socio-cultural factors. For example, John
Bancroft, former director of the Kinsey Institute, disputes the use of the term ‘Female
Sexual Dysfunction’, claiming it paints a false picture of a disordered organic process,
where in fact, it may be the case that a women’s lack of desire for sex, or difficulty
feeling aroused, stems from everyday stress and tiredness (Bancroft, 2002). Bancroft
cautions: “The danger of portraying sexual difficulties as a dysfunction is that it is
likely to encourage doctors to prescribe drugs to change sexual function – when the
attention should be paid to other aspects of the woman’s life. It’s also likely to make
women think they have a malfunction when they do not” (cited in Moynihan &
Cassels, 2005, p. 188).
Sandra Leiblum, psychiatrist and instigator of the additional diagnostic
category Persistent Sexual Arousal Disorder (see Leiblum & Nathan, 2001), has also
voiced doubts about the new classification system of FSD. Leiblum is one of the few
medical experts (along with Bancroft) who acknowledges the historical
pathologization of women’s sexuality within masculinist frameworks (Loe, 2004).
While conceding FSD has its roots in old psychiatric notions of frigidity, she contends
the revised approach still improves on previous classifications “by avoiding
oversimplicity and embracing the many dimensions (relational, psychological, and
physiological) of women’s sexual problems” (cited in Loe, 2004, p. 131). At the 2001
Boston Forum, Leiblum also stressed the importance of another non-organic factor
impacting on women’s sexual well-being, something she termed the “Steve Problem”,
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which emphasized the part (heterosexual) women’s sexual partners play in
dissatisfying sexual experiences (cited in Loe, 2004, p. 154).
Psychiatrist Rosemary Basson, a member of the Female Sexual Function
Forum, leads many of the publications advocating changes to the previous
classification system of women’s sexual problems; however, as mentioned, she has
also provided alternative (though medically influenced) models of women’s sexual
response to the standard HSRC proposed by Masters and Johnson and employed in
the DSM. Basson’s (2000, 2001, 2004, 2005) versions recognize contextual factors,
such as the impact of long-term sexual relationships, on women’s sexual experiences.
The New View approach to women’s sexual problems: “A historically-situated
attempt to contest medicalization”2
Ever since Viagra proved to the pharmaceutical industry that contemporary
sexual confusions and dissatisfactions could be medicalized and marketed (to
the sweet cash register ring of billions of dollars and Euros), companies have
been searching for some way to make women into sex problem consumerpatients (Tiefer, 2003, p. 2).
During the last decades of the 20th century, feminist scholars mounted a
concerted challenge to medicine’s reductionist, androcentric constructions of
normative sexuality. For example, Leonore Tiefer (1995) critiqued the HSRC and
definitions of sexual dysfunction; Nellie Oudshoorn (1994) and Jennifer Harding
(1998) interrogated the ways in which hormones came to be reified as determinators
of male and female sexualities; Lana Thompson (1999) and Carol Groneman (2001)
traced the history of cultural fallacies such as ‘the wandering womb’ and
‘nymphomania’ respectively; Rachel Maines (1999) analyzed the medical treatment
of ‘hysteria’ at the turn of the 20th century (which involved doctors inducing orgasms
in women via the use of early vibrators); and Paula Nicolson (1993) identified three
key discourses prevailing in medical and popular cultural definitions of ‘normal’
sexuality (the coital, orgasmic and biological imperatives).
This tradition of providing critique of - and counter-perspectives to - the
medical model prevails in relation to the contemporary biomedicalization of women’s
sexuality. In response to the early meetings arranged by Goldstein, New York based
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clinical psychologist and sexologist, Leonore Tiefer, brought together a group of
social scientists, clinicians and feminist activists to form a group called The New
View Working Group, which has provided effective and highly-publicized opposition
to this latest bid to define and control women’s sexuality. Tiefer exposed the closeddoor invitation-only nature of the original meeting organized by Goldstein in 1998
(six months after FDA approval and launch of Viagra), as well as drug company
affiliations of most contributors to this meeting. She is also largely responsible for
critiquing the so-called objectivity of the consensus report and the revised framings of
FSD (Tiefer, 2001).3
New View campaigners argue that the recently developed classification
system for FSD centres on the continued medicalization of women’s bodies and
sexualities in more intensely technologized and commercialized modes. While
acknowledging that medical problems do exist, the group is concerned about the
primacy of biophysiological explanations and solutions for women’s sexual problems
endorsed by a medical establishment heavily influenced by the corporate world of the
pharmaceutical industry. Advocates of the New View argue that commercial interests
are central to moves in the field of FSD, a process Geradline Treacher (2003, p. 30)
eloquently describes as “FSD as pharmaceutical project”.
Because there are no magic bullets for the socio-cultural, political,
psychological, social or relational bases of women’s sexual problems,
pharmaceutical companies are supporting research and public relations
programs, focused on fixing the body, especially the genitals. The infusion of
industry funding into sex research and the incessant media publicity about
‘breakthrough’ treatments have put physical problems in the spotlight and
isolated them from broader contexts (New View Working Group, 2001, p. 4).
To challenge the predominance of the medical model of FSD, the New View
group has devised their own counter document to the Consensus Committee’s report,
which critiques current trends in the diagnosis and treatment of women’s sexual
concerns, and offers a more expansive, holistic classification system. This manifesto,
called The New View of Women’s Sexual Problems, co-authored by 12 clinicians and
social scientists in 2001, targets the medical model for its universalist underpinnings,
arguing this approach promotes a “false notion of sexual equivalency between men
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and women”, leads to the “erasure of the relational context of sexuality”, and fails to
address diversity among women (New View Working Group, 2001, p. 3).
The categorization system devised by the New View group focuses on four
key dimensions:
‘sexual problems due to socio-cultural, political, or economic factors’
(including inadequate access to information about gender roles, sexual
biology, contraception and abortion, sexual trauma and STD prevention) and
‘sexual avoidance or distress due to perceived inability to meet cultural norms
regarding correct or ideal sexuality’ (including issues such as shame about
one’s body and confusion about sexual identity); ‘sexual problems relating to
partner and relationship’ (including sexual concerns due to abuse, conflicts,
history or traumatic experiences); ‘sexual problems due to psychological
factors’ (including depression and anxiety, past traumatic experiences, fear of
consequences of pregnancy and pain etc); and ‘sexual problems due to
medical factors’ (eg, neurological, neurovascular, endocrine conditions, side
effects of drugs, iatrogenic conditions, pregnancy, STIs etc) (New View
Working Group, 2001, p. 4).
Members of the New View campaign contend its strength lies in its resituation of women’s sexuality in the political, rather than medical, domain (Hartley
& Tiefer, 2003). By highlighting the insights of women’s studies and critical sex
research, and focusing on preventative strategies that offset the socio-political and
economic causes of sexual problems, the New View approach disrupts simplistic
biomedical frameworks of FSD. The New View campaign has received significant
publicity through numerous publications (including an edited volume and a teaching
manual), via its website www.fsd-alert.org, and through two conferences, the first in
San Francisco in 1999, and the second (and closing conference of the campaign) in
Montreal in 2005.
Women’s own perspectives on ‘pink Viagra’
While the ‘expert’ voices of the proponents and opponents of FSD have been
heard through the media and various medical and academic forums, the opinions of
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women themselves have received less attention. To date few studies exist specifically
focusing on women’s perspectives on the construction of sexual problems within
medicalized frameworks and/or the development and advent of sexuopharmaceuticals
targeting women (although see Treacher, 2003). However, women participating in
research on the impact of men’s use of Viagra (for the treatment of erectile
difficulties) have provided some insights (Potts et al, 2003; Potts et al, 2004; Potts,
2005; Loe, 2004; Askew & Davey, 2004). This section concentrates on the accounts
of women in one such study, a qualitative project undertaken between 2001 and 2004,
which was funded by the Health Research Council of New Zealand (Potts et al, 2003,
2004, 2005).4 The chief purpose of the interviews with the 27 women taking part in
this study was to explore their experiences of erectile difficulties and Viagra use in the
context of their relationships with men; however, women also took the opportunity to
talk about the development of drugs to treat women’s sexual difficulties.
Few, if any, of the women in this study were aware of the FSD debate which
was occurring at the time of their interviews, therefore their responses pertain more to
speculations on the anticipated advent of a Viagra-type drug for women, than to any
informed engagement with this particular debate. Nevertheless, and perhaps not
surprisingly, the responses of women in the New Zealand study resonate with proand anti-biomedicalization perspectives on FSD. First explored are women’s concerns
about the advent of pink Viagra; this is followed by a discussion of the perceived
benefits of sexuopharmaceuticals catering for women.
Women’s concerns
New pressures: Women in the New Zealand study expressed various concerns
about the use of Viagra by men within sexual relationships. These included pressure
to have sex following a partner’s consumption of Viagra, an increased focus on
intercourse at the detriment of other forms of sexual activities, and difficulties
negotiating sex following use of the drug (Potts et al, 2003). For example, several
participants in the New Zealand study reported it felt more difficult not to have sex
(that is, to decline sex) once they knew their partners had used Viagra; once a pill was
taken, it ‘committed’ them to sex; and some spoke about ‘putting up with sex’ when
they really didn’t feel like it (Potts et al, 2003).The difficulty declining sex was in
some cases associated with a concern to please one’s partner – ‘not to let him down’.
14
In her American study of senior women’s attitudes to Viagra use by men, Meika Loe
(2004) also noted this kind of response, with participants conveying they felt pressure
to ‘please their partners’ following use of the drug, as part of a wifely obligation.
When asked about the implications of pink Viagra, some women in the New
Zealand study speculated this could place even more pressure on women. For
instance, new demands might come from men wanting women to take drugs too, in
order to match the newfound youthful virility associated with their own use of Viagra
or other sexuopharmaceuticals. One 60 year old expressed doubts about the less
intimate experience of sexual relations this would produce:
[My husband] was also wanting me to take Viagra … because apparently it’s
supposed to work on women too, and I said what I would have liked … was a
little bit of romance back in the relationship, but it wasn’t like that at all. It
was Viagra, right, you make an appointment for sex, and now I have to know
x number of hours before and so there’s no use me taking this pill and then
you not being receptive and so on, and I’m thinking to myself… oh, I don’t
know if I want to bloody feel like that today, you know?
Rejecting a ‘quick fix’: Women also challenged the notion of drugs as a ‘quick
fix’ for sexual problems. For some, the use of sexuopharmaceuticals by partners had
in effect caused new problems (tension and conflict) within relationships, rather than
resolved issues (Potts et al, 2004). Several commented that medication was an
inadequate solution for sexual difficulties that were as much about relational problems
as organic ones. For this woman, aged 51, the perceived artificiality of any drug also
posed a problem for what she termed women’s ‘natural’ sexuality:
I think a woman should be left natural, it should be a natural instinct to a
woman, and if she doesn’t feel like having sex, or is having problems, there’s
usually an underlying reason why. And I don’t think that can be overcome or
fixed by just poking drugs into her. A lot of women, they’re just tired, they’re
stressed out and so forth … I’m not in agreement with women taking artificial
things to boost them.
15
Interestingly, a few women reported that when Viagra or other medical
interventions had not been able to ‘fix’ erectile difficulties, they had noticed an
improvement in sexual relations with male partners, which they tended to explain in
terms of an expansion of sexual repertoires since certain habitual modes of relating
sexually (such as penetrative sex) were no longer an option. One 50 year old
explained:
It’s actually probably made it better ... You try other things as well, because
it’s not that easy, so you do more of other foreplay and all sorts of things … so
it actually probably has improved things, rather than not ... I guess we are
doing different and more things than we were doing before.
Thus, the very ‘problems’ the medical model of sexuality identifies and targets
for rectification (that is, non-erections in men, inability to complete coital sex) were
actually experienced as non-problematic in the context of this relationship, and
medical definitions of dysfunctionality did not apply.
The trouble with (one minute) men: One of the ways women may resist the
biomedical model of FSD is through locating the cause of women’s sexual problems
in the hands of men (quite literally). In an in-depth study of a small group of women’s
opinions about the medical construction of FSD and the development of
sexuopharmaceuticals for women (associated with the New Zealand project),
Geraldine Treacher (2003) detected the existence of a ‘lousy lovers discourse’
(similar to the ‘Steve problem’ proposed by Leiblum), in which women blamed a
sexual partner’s lack of proficiency for FSD. For example, one participant in her 50s
commented:
Lack of sexual gratification in women isn’t about that [a topical crème]. I
actually think it’s about people taking the time to make it nice for the other
person. I think that’s what’s wrong with a lot of women in my generation, men
that really just don’t have a clue. The one minute men. (cited in Treacher,
2003, p. 86).
16
The idea of ‘lousy lovers’ or ‘one minute men’ contributing to women’s
sexual dissatisfaction was evident in both heterosexual and lesbian women’s accounts
in Treacher’s study. She comments that the ‘lousy lovers’ discourse challenges the
medicalization of women’s sexual difficulties as it implies that some of the so-called
43% of women experiencing sexual dissatisfaction cannot be labelled dysfunctional,
and a drug will not be a sufficient ‘cure’ (Treacher, 2003).
Resisting the pharmaceutical industry: The involvement of the pharmaceutical
industry in the increasing hype around women’s sexual difficulties did not escape
scrutiny in the New Zealand study. One woman (aged 27) argued that drug companies
were putting pressure on women and men to fixate on physical aspects of sexuality,
and worry about whether or not their sexual relations were adequate (in the context of
medicalized assumptions about normality):
Actually I think most of it is a lot more social, cultural, psychological kind of
thing, and I think it’s all of those things that are a bit more inhibiting. I
actually feel a bit sick when I see these drug companies coming out … and
saying that women have to take this and this. It’s like a flipping pill to fix this,
and a pill to fix that … without actually addressing perhaps some of the deeper
issues that a woman is facing like extra pressures of being a mother … and
subsuming her own sexual desires for the male, you know, living in a
patriarchal society and all those kind of things which are probably more likely
to inhibit her sexual arousal than anything that’s kind of physiological. Yet the
drug companies jump on the bandwagon and say take this creme and it’ll fix
you… It’s quite sickening really… It’s a quick fix.
This criticism of the pharmaceutical industry’s creation of the ‘need’ for
sexuopharmaceuticals (a position which is of course upheld by the New View group)
has also been expressed by men and women in a focus group study about
representations of Direct To Consumer advertising of Viagra.5 Participants in this
study blamed drug companies for producing assumptions about the benefit of drugs
like Viagra through “peddling fear” – creating “performance anxieties” – in ‘normally
functioning’ people (Vares et al, 2003, p. 101; see also Askew & Davey, 2004). This
concern was also raised by a 60 year old woman who contended that the ‘hard sell’
17
surrounding Viagra had caused people to believe they were defective. She viewed the
changes in sexuality associated with aging, for example, as part of a natural rather
than pathological (or disease) process.
Up until Viagra … nature took care of it and men’s ability went down equally
with women getting older, losing the same desire that they had when they
were young women … I think Viagra has made a lot of people feel inadequate
… everybody’s on the defence about how often they have sex and so on, in the
older age group.
Perceived benefits
Keeping sexually active: Enthusiasm for the advent of a pink Viagra was also
evident in the New Zealand study. One woman (aged 52) commented:
The faster they can get them on the market the better… because I keep
thinking – and I’ve discussed it quite a lot with friends of mine - we’re all
roughly heading towards the senior citizens status. Once you hit sixty I think,
well, that’s it. But what do you do? I mean you could have a raging sex life in
your old age, if you organized it properly, and if you get your health straight…
You’ve got to be fit, and I think the fitness factor for older people is going to
be absolutely crucial.
This woman frames the new impetus to keep fit and active (including
sexually) as essential to health in mid to later life. Critical gerontologists Barbara
Marshall and Stephen Katz (2002) have read this contemporary drive to maintain
‘busy bodies’ in older age as a new form of social pressure associated with late
capitalism and biomedicalization. They argue that sexuality is one field receiving the
hardest push, especially by pharmaceutical companies urging potential consumers to
purchase the latest sex drug that will enable them to remain ‘forever functional’ (that
is, sexually active for life).
Equal rights to sexuopharmaceuticals: Another woman (aged 53), who had
tried Viagra (without any noticeable effect), argued that sexuopharmaceuticals should
18
be readily accessible for women as a matter of gender equity. She contended men’s
sexual needs had historically been prioritized, and that it was a matter of equality women were entitled to the same (potential) benefits as men.
What I do have difficulty with is drugs aren’t available for women. I feel
annoyed about that … It seems like men’s sexuality is catered for on many
different levels, and I don’t think ours is … For example there hasn’t been the
interest in women’s sexuality to the same degree … I would like women to
have the freedom to take something - as long as it was comparatively safe. I
think women should have that option.
In their London based study of the women’s experiences of Viagra use within
relationships, Julie Askew and Maureen Davey (2004) noted similar responses from 3
of the 4 women they interviewed. These women were particularly interested in drugs
that might enhance arousal. Similarly, several women in Loe’s American study
reported that some form of pink Viagra would be welcomed by them. However, Loe
(2004) argues that women’s desire for Viagra-type drugs may be motivated by
different factors to men’s desire for Viagra: “while men may need the drug to help
them continue their sexual pleasure, women may want the drug to discover theirs for
the first time” (p. 105).
Interestingly, one woman in the New Zealand study (aged 50) speculated
that, while women should have the same access to sexuopharmaceuticals pills as men,
men wouldn’t want them to. She based this assumption on the idea that men need to
be the ‘experts’ on women’s sexuality, and feel they have produced pleasure (through
orgasm) for their partners; a pill consumed by women would take this sense of sexual
authority and know-how away from men.
Summary
While the construction of women’s sexuality as aberrant has a long history in
western culture, in the 21st century we are witnessing the growing impact of
biomedicalization on catergorizations of normal and pathological sexuality, forms of
diagnosis, and modes of treatment. In line with the biomedical perspective’s
propensity to view sexual difficulties as either having organic foundations, or at least
19
the capacity to be treated by physical means, pharmacological preparations are
increasingly considered first-choice ‘quick fix’ interventions on the road to ‘recovery’
from sexual problems. Accordingly, sexual experiences are likely to be more and
more understood within a framework emphasizing anatomical and biophysiological
‘facts’ about the sexual body, and the importance of blood flow and hormones on
‘genital wellness’. FSD has emerged as a new term that more or less repackages old
‘problems’ such as frigidity (Askew, 2004), nymphomania and hysteria (in its
construction of desire, arousal and orgasmic disorders).
However, FSD remains a disputed illness; and the treatment of women’s
sexual difficulties with sexuopharmaceuticals continues to be controversial. The
Boston Forums on Female Sexual Dysfunction, held annually since 1998, represent
events on one side of the current biomedicalization debate. Sponsored by drug
companies, and attended by medical professionals and sex researchers with
connections to the pharmaceutical industry, these meetings proclaim to have
progressed fairer, more expansive classifications of women’s sexual problems than
those previously listed in the DSM IV. While opening up diagnostic criteria to
acknowledge the importance of subjective experience and personal distress, as well as
contextual factors, the new constructions of FSD firmly endorse a biophysiological
framing of women’s sexual difficulties, and pave the way for biomedical interventions
(especially drugs such as hormones and vasodilators) to be viewed as the most
effective modes of rectifying sexual problems, regardless of aetiology.
While several physicians associated with the biomedical perspective have
voiced reservations about aspects of the new classification system for FSD, the most
vocal opposition has stemmed from anti-medicalization activism, led by Leonore
Tiefer and the New View campaigners. This group of social scientists, clinicians and
feminists has challenged the predominant framing of women’s sexual distress from
within a reductionist biological model, rallied against the commercialization of
sexuality (and the influence of Big Pharma on societal conceptualizations of ‘normal’
and ‘abnormal’ sex), and provided an alternative holistic classification system for
women’s sexual problems, which gives equal weight to psychological, emotional,
contextual, relational, and socio-cultural factors, as well as physical ones.
The debate between pro-biomedicalization and anti-biomedicalization factions
continues, although an important victory was achieved by advocates of the New View
in December 2004 when the FDA declined to approve a hormonal preparation
20
(Intrinsa) manufactured by Proctor and Gamble for the treatment of Female Sexual
Arousal Disorder. Although those connected with the anti-medicalization group
present at the FDA hearing drew attention to numerous potential problems for women
associated with use of this drug, it was the medical risk factors that held the most
weight; Intrinsa was rejected on the grounds that it may increase the likelihood of
breast cancer, heart attack or stroke (Spark, 2005). While the New View campaign
was officially ended by Tiefer at the 2nd conference of supporters in Montreal, July
2005, those opposed to the growing influence of biomedicine on all aspects of life,
continue to critique and challenge this process and its links to late capitalism.
Not surprisingly, the perspectives of women themselves regarding medicalized
understandings of women’s sexuality (and the advent of sexuopharmaceuticals
targeting women) line up on both sides of this debate. Despite not having an overt
awareness of the contemporary FSD debate, their accounts are nevertheless
influenced by the same kinds of arguments that prevail in the different factions of this
dispute. This indicates that medicalized constructions of women’s sexuality (and
sexual difficulties) are being contested both at institutional levels (for example, in the
language of experts) and at the discursive level (in women’s everyday lives and
experiences). Some women enthusiastically endorse the development of a sister drug
to Viagra, citing reasons such as gender equity (the fairness of such drugs being
available for women as well as men), and the perceived benefits of these drugs in
maintaining sexual ‘fitness’ and ‘function’ across the life-span. These women,
positioned within the medical model of sexuality to various degrees, also draw on
contemporary discourses advocating the requirement to retain ‘busy bodies’ and
remain ‘forever functional’ in later life (Marshall & Katz, 2002). Others are less
convinced about the advantages of pink Viagra, expressing concerns about possible
unwelcomed changes to relationships, and potential new expectations and demands
from male partners for women to take sexuopharmaceuticals too. Women may also
resist the medical model’s pathologization of the changes in sexuality associated with
growing older; they may reject the artificiality of sexuopharmaceuticals, perceiving
drugs to interfere in ‘natural’ sexual relations; and they may challenge the
commodification of sexual problems by Big Pharma.
The advent of Viagra-type drugs for women is inevitable. And while such
drugs will no doubt benefit some women whose sexual experiences are compromised
21
primarily by medical/physical problems (such as neurological conditions), it is
important to critically engage with any broader application of these interventions. The
biomedical perspective, in its advocacy of a universal body and human sexual
response, has tended to rely on generalizations about sexuality, producing a concept
of sexual normality (heterosexual, coital, orgasmic, with masculine sexuality
understood as more active and penetrative, and feminine as receptive or passive)
against which other forms of sexuality, sexual practice, sexual response and
experience are measured and rendered abnormal, disordered, diseased or
dysfunctional. Within this reductionist model, the complexities of both women’s and
men’s sexualities and relationships are by-passed or rendered problematic, and there
is little room for alterative sexualities or experiences. Those not conforming to the
conventional notion of ‘normality’ are marginalized and pathologized. In the wake of
increasing biomedicalization and the race to develop and market pink Viagra, it is
crucial to ensure that alternative sexual practices and pleasures (such as heterosex
without erections, and non-penetrative sex) are not marginalized or trivialized, but
instead visibly promoted as viable, sexy alternatives.
Acknowledgements
I am grateful to Pamela Moss and Kathy Teghtsoonian for the opportunity to
report on the FSD debate, as well as the Institute of Gender and Health (of the
Canadian Institutes for Health Research) and the Social Sciences and Humanities
Research Council (Canada) for funding my participation at the Illness and the
Contours of Contestation workshop, Victoria, BC. Thanks also to the participants and to my colleagues - on the project “Sex for life? The sociocultural implications of
sexuopharmaceuticals”, and especially Geraldine Treacher for her pioneering work in
this area in the New Zealand context.
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The term ‘pink Viagra’ entered popular vernacular through journalistic reports and popular media.
From Tiefer, 2001, p. 89.
3
Tiefer’s work is complemented by the arguments of those involved in anti-psychiatry activism,
including several prominent authors with medical backgrounds (Healy, 2004; Metzl, 2003; Elliot,
2003), and by journalists critical of the increasing influence of Big Pharma (Moynihan, 2003;
Moynihan and Cassels, 2005).
4
“Sex for life: The sociocultural implications of prosexual pharmaceuticals for men and women”
(Principal Investigator: Annie Potts; Co-Investigators: Victoria Grace, Nicola Gavey and Tiina Vares).
5
Direct To Consumer advertising (DTC) permits the direct promotion of drugs (including lifestyle
drugs like Viagra) to potential consumers (via television and radio, and magazine adverts), and occurs
in a handful of countries, including the United States and New Zealand
1
2
28