Last week, Sprout Pharmaceuticals resubmitted its drug flibanserin to the Food and Drug Administration for approval. Flibanserin, in case you haven’t heard, is a drug intended to treat low sexual desire in women. The F.D.A. has rejected it twice already, and will most likely reject it a third time because (if you’re Sprout) the F.D.A. is sexist or (if you’re the F.D.A.) the drug doesn’t work and isn’t safe.
But the biggest problem with the drug — and with the F.D.A.’s consideration of it — is that its backers are attempting to treat something that isn’t a disease.
Flibanserin purportedly treats a condition called hypoactive sexual desire disorder in women. But H.S.D.D. was removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 2013, and replaced with a new diagnosis called female sexual interest/arousal disorder, or F.S.I.A.D.
Why the change? Researchers have begun to understand that sexual response is not the linear mechanism they once thought it was. The previous model, originating in the late ’70s, described a lack of “sexual fantasies and desire for sexual activity.” It placed sexual desire first, as if it were a hunger, motivating an individual to pursue satisfaction. Desire was conceptualized as emerging more or less “spontaneously.” And some people do feel they experience desire that way. Desire first, then arousal.
But it turns out many people (perhaps especially women) often experience desire as responsive, emerging in response to, rather than in anticipation of, erotic stimulation. Arousal first, then desire.
Both desire styles are normal and healthy. Neither is associated with pain or any disorder of arousal or orgasm.
The new diagnosis is intended for women who lack both spontaneous and responsive desire, and are distressed by this. For these women, research has found that nonpharmaceutical treatments like sex therapy can be effective.
But I can’t count the number of women I’ve talked with who assume that because their desire is responsive, rather than spontaneous, they have “low desire”; that their ability to enjoy sex with their partner is meaningless if they don’t also feel a persistent urge for it; in short, that they are broken, because their desire isn’t what it’s “supposed” to be.
What these women need is not medical treatment, but a thoughtful exploration of what creates desire between them and their partners. This is likely to include confidence in their bodies, feeling accepted, and (not least) explicitly erotic stimulation. Feeling judged or broken for their sexuality is exactly what they don’t need — and what will make their desire for sex genuinely shut down.
Apparently we still haven’t learned our lesson about what happens when we pathologize normal sexual functioning.
In a 1972 issue of The Journal of Nervous and Mental Disease, the neurologist Robert G. Heath reported that he had recorded the brain activity of a young man suffering from epilepsy and “severe mental illness,” including “a five-year history of overt homosexuality.
The patient had electrodes implanted in his cortex, which was then thought to control pleasure. He was given a “three-button self-stimulating” device, with which he could zap his own brain for three hours at a time — which he did, about once every 10 seconds. Researchers showed him stag films (read: porn), introduced him to a female prostitute and measured his brain activity during heterosexual intercourse. Dr. Heath said the treatment was effective.
A year later, homosexuality was voted out of the Diagnostic and Statistical Manual. Now, of course, only a fringe minority of the medical community would suggest that sexual orientation is anything other than a normal aspect of human sexuality.
This analogy between desire style and sexual orientation is imperfect: There is no reason to suspect that responsive or spontaneous desire is innate. In fact all desire is somewhat responsive, even when it feels spontaneous. But Dr. Heath and Sprout are both part of the long history of trying to call “diseased” what is simply different.
When a woman experiencing responsive desire comes to understand how to make the most of her desire, she opens up the opportunity for greater satisfaction. Outdated science isn’t going to improve our sex lives. But embracing our differences — working with our sexuality, rather than against it — will.
(From NY Times)