Feature

Ever since Viagra first appeared on the scene a decade ago, the pharmaceutical industry has been searching for a similar blockbuster for women—what some call the "pink Viagra."

Companies are busy testing potential products that include a nasal spray, pill, skin patch and injection—all designed to boost low libidos in women. The German company Boehringer Ingelheim hopes to win approval for its contender from the U.S. Food and Drug Administration next year. And physicians are already giving women off-label prescriptions for testosterone.

Some psychologists welcome the prospect. Often working with the pharmaceutical industry, they are eager to add another option to treatment for low desire in women. Other psychologists find the push for pharmaceutical treatment dismaying. For them, such efforts—and even the diagnosis itself—represent a pathologizing of normal variation in the hopes of financial profit.

Methodological barriers

It wasn't just Viagra's popularity that sparked the rush to find a female equivalent. Another impetus was a widely reported 1999 study in the Journal of the American Medical Association (Vol. 281, No. 6) that claimed 43 percent of American women between 18 and 59 experienced such signs of sexual dysfunction as lack of desire, arousal difficulties, inability to achieve orgasm, anxiety about sexual performance, climaxing too quickly, physical pain during intercourse or a failure to find sex pleasurable.

A more recent study funded by Boehringer Ingelheim and published in November in Obstetrics & Gynecology (Vol. 112, No. 5) found that 40 percent of the almost 32,000 participants reported sexual issues. However, only 12 percent of the women felt distressed as a result. And there were variations by age, with older women experiencing more dysfunction but less distress over it.

Several methodological issues make research on female sexual dysfunction difficult, warns psychologist Leonard R. Derogatis, PhD, director of the Center for Sexual Health and Medicine at Sheppard Pratt Hospital and associate professor of psychiatry at the Johns Hopkins School of Medicine. One problem is the sheer complexity of women's sexual functioning, says Derogatis. Men's sexual functioning is like a machine with an on/off switch, he points out, while women's is like a machine with a huge array of dials.

Another barrier is the lack of a diagnostic "gold standard," says Derogatis, who has developed instruments to help fix that. The Women's Sexual Interest Diagnostic Interview gives clinicians a structured way to diagnose hypoactive sexual desire disorder. A 2008 study by Derogatis and colleagues, published in the Journal of Sexual Medicine (Vol. 5, No. 12), found that both clinician-administered and self-report versions successfully identified the disorder in acted-out scenarios developed by experts.

Derogatis has also developed a scale for measuring sexually related personal distress in women, an instrument whose usefulness was demonstrated in a study he and colleagues published in 2008 in the Journal of Sexual Medicine (Vol. 5, No. 2).

Derogatis is exasperated by critics who claim that low desire is a marketing ploy. "No one ever said erectile dysfunction was a myth or all in men's heads or made up by drug companies, yet they're perfectly willing to adopt that posture for women," he says.

Derogatis, who works with the pharmaceutical industry, is equally impatient with those unwilling to use medicine to treat what he sees as primarily a medical issue—low desire caused by a drop in women's testosterone levels. Physical problems, he says, demand physical solutions—something he and other psychologists are trying to achieve.

Sheryl A. Kingsberg, PhD, president of the International Society for the Study of Women's Sexual Health and another industry consultant, agrees that women distressed by low levels of desire need more options.

"The prevalence of female sexual problems is so great that anything we can do to add to our repertoire for these women in distress is a bonus," says Kingsberg, chief of the behavioral medicine division at MacDonald Women's Hospital at University Hospitals Case Medical Center and associate professor of reproductive biology and psychiatry at Case Western Reserve University in Cleveland.

In a 2007 study funded by Procter & Gamble Pharmaceuticals and published in the Journal of Sexual Medicine (Vol. 4, No. 4), she and colleagues examined the effect of testosterone on women who had entered menopause prematurely following removal of their ovaries. They found that about half of the women who received testosterone patches reported meaningful benefits. (So did 31 percent of those who received placebo patches.) Among those who reported benefiting from testosterone treatment, the number of satisfying sexual episodes per month more than doubled. And those who benefited wanted to continue, says Kingsberg.

That's not to say all cases of sexual dysfunction should be treated with a testosterone patch, she notes. "If someone has a biological problem, trying to guide them through couples therapy or the underlying psychological issues that have caused them to no longer desire sex is going down the wrong path," she says. "On the other hand, if someone is unhappy with her spouse, no amount of testosterone is going to fix that."

Medicalizing women's sexuality?

Other psychologists don't agree that pharmaceutical interventions are the answer. Among them is Leonore Tiefer, PhD, co-editor of "A New View of Women's Sexual Problems" (Haworth, 2001) and clinical associate professor of psychiatry at the New York University School of Medicine.

"It's not that there aren't any sex problems," she says. "It's a question of what you call them, how you decide which things are really problems and how you organize your thinking about them."

In 2000, she was part of a group that launched an educational, advocacy and empowerment effort called the New View Campaign to counter what they see as "disease-mongering" by the pharmaceutical industry and its allies.

Tiefer is convinced that physical issues account for a "minuscule" percentage of women's sexual problems. She's worried about the dangers of drugs, including possible side effects, interactions with other medications and unforeseen long-term consequences for women's health. And she's concerned that diagnosing low desire as a dysfunction—and treating it with drugs—obscures the physiological differences between men's and women's sexual responses, ignores the relational aspect of sex and assumes that all women approach sex the same way.

"The medical model says that normal sexual functioning consists of regular, routine, reliable arousal and orgasm, and that's it," says Tiefer. "It doesn't say anything about the enormous range, variation and diversity."

Besides, she says, research shows no correlation between circulating levels of testosterone and desire. "This is one of those simple-minded messages the industry is so attracted to," she says.

At the heart of the New View's approach is an expanded classification that goes far beyond the merely medical. To help women who decide changes in their desire are a problem, clinicians should replace the current classification system with one that takes into account the sociocultural, political, economic, interpersonal, psychological and medical factors that affect women's sexuality. Such factors could include ignorance due to inadequate sex education, anxiety or shame about one's body, discrepancies in desire levels, fatigue due to family or work obligations, fear of one's partner, depression, a history of abuse, pregnancy and medication side effects.

The New View's proposed classification system mirrors how women themselves view their sexual problems, says Leanne Nicholls, ClinPsyD, a clinical psychologist for the Avon and Wiltshire Mental Health Partnership Trust in Bristol, England.

In a 2008 study published in Feminism & Psychology (Vol. 18, No. 4), she used a survey to test the New View classification scheme's usefulness. Sixty-five percent of the 49 respondents attributed their sexual difficulties to relationship problems, 20 percent to contextual factors and 8 percent to psychological issues. Only 7 percent cited medical problems as the cause.

"The most important factor for women themselves was their relationships," says Nicholls. "It seems a bit crazy that predominantly biomedical classification systems or conceptualizations overlook that."

In another article in the same issue, Kathryn Hall, PhD, a private practitioner in Princeton, N.J., and author of "Reclaiming Your Sexual Self: How to Bring Desire Back into Your Life" (Wiley, 2004), offers a qualitative study of the New View in practice with adults who have experienced childhood sexual abuse.

In one case study, a lesbian couple complained of one partner's lack of sexual interest. Testosterone supplements hadn't worked.

In keeping with the New View's emphasis on letting clients define both the problem and desired outcome, Hall helped the couple realize that the real issue was the relationship's power imbalance.

To Derogatis, that approach is not incompatible with the pharmaceutical approach he champions. In fact, he says, he recommends psychological treatment alongside pharmaceutical treatment.

"It's not us against them," says Derogatis, calling for psychologists to collaborate with physicians. "It's us with them."


Rebecca A. Clay is a writer in Washington, D.C.