This long-form scholarly blog entry is authored by Dr. Alyson K. Spurgas, Assistant Professor of Sociology at SIUE. Dr. Spurgas regularly teaches courses in the Women’s Studies minor including Gender & Society. Her research expertise lies primarily in medical sociology, which uses sociological analysis to examine medical organizations and institutions including the production of knowledge within medicine, the actions and interactions of healthcare professionals, and the social or cultural effects of medical practice. In this blog entry, Dr. Spurgas reflects on how medicine interacts with sexuality and gender norms by focusing on the notion of a “female Viagra.” What ideas about sexuality, she asks, do we reinforce by how we both diagnose and treat “low female desire”? Is it a problem that part of the technical diagnostic criteria involve how receptive a woman is to her partner’s advances? Why does the treatment for this target women’s minds (their desire), when men’s treatments for sexual dysfunction target their physical performance?
Since the unprecedented success of Viagra in the late 1990s, pharmaceutical companies in the United States and abroad have been on a tortuous search to corner the market in a drug to treat women’s sexual dysfunction. A variety of methods have been dreamed up, tested in clinical trials, and evaluated by the U.S. Food and Drug Administration (FDA)—including a testosterone patch, a hormonal nasal spray, and what will now certainly go down in history as the most successful—an ingestable oral tablet.
The image shows a small pink-peach colored pill laying on top of a brochure for Sprout Pharmaceuticals. IMAGE CREDIT: Allen Breed/AP
Some have called this pill, prescribed to enhance women’s sexual desire, the “pink” or “female” Viagra—but, thoughtful citizens and potential consumers might ask: how similar are the two drugs, in terms of chemical make-up, design, and prescribed treatment regimen? Upon comparing the two medications, it becomes clear that they are in fact far from equivalent (or even similar). In addition to contrasting the mechanisms of the two drugs, it might be equally important to examine the assumptions being made about men’s and women’s sexuality as these drugs are produced and consumed, or the theories of sexuality and sexual difference being administered to patients alongside the drugs themselves. In order to uncover these hidden theories of sexual difference, I take a look at how men’s and women’s sexualities are configured within contemporary—and more antiquated—medical and scientific discourses. Through a brief exploratory comparison, one thing becomes evident—women have consistently been framed as very different from men, sexually, and this has undoubtedly impacted our experience of our own sexual self-determination, agency, desire, and pleasure. And, perhaps more surprisingly, regardless of what drugs are now available, this pattern continues in the present day. It seems that as much as medicine and science have changed since the 18th century, many characterizations of masculinity and femininity have remained the same.
With the inception of modern medicine in the Victorian Era, sex became an object of scientific study. And from the earliest sexology texts onward, gender differences have been assumed and discursively reproduced. In early medical textbooks, women were depicted as sexually deviant—the vagina was thought to be an “inverted” penis, and women were framed as inferior, sometimes as constitutionally asexual, or, at the very least, as innately lower in sexual desire than men. Female sexuality was also characterized as complex, complicated, wayward, and peculiar—nothing like the straightforward, potent, goal-oriented, and virile sexuality of men. These ideas about men’s and women’s sexualities have persisted in a variety of guises through many different psychological and psychiatric paradigms—from sexology, to psychoanalysis, to our current biopsychiatric and neuroscience-based explanations and treatments. Within contemporary sexual medicine and studies of pathology, men are perceived as disproportionately likely to suffer from physiological ailments such as erectile disorder, whereas women are understood as more likely to suffer from psychological blocks to optimal sexual enjoyment. And in our current quick-fix climate, these perceived differences in sexuality translate into drastically different framings and treatments of sexual dysfunction for men and for women, with gender-differentiated consequences for sexual health, attitudes, and relationships—among both “dysfunctional” and “healthy” populations.
Take, for example, the new gender-specific sexual desire disorders in clinical psychology literature, and their corresponding gendered models of desire and sexual response. In the newest Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013)—what is generally understood to be the contemporary psychiatrist’s “bible”—the diagnosis of “Female Sexual Interest/Arousal Disorder” (FSIAD) includes lack of sexual receptivity as a core component of sexual dysfunction—and is diagnosed in women only. This new female-specific diagnosis did away with the older gender-neutral “Hypoactive Sexual Desire Disorder” or HSDD; before the publication of the DSM-5, HSDD was the diagnosis that both low-desiring men and low-desiring women received. Now, for the first time in the history of the Manual, the diagnoses are gender-differentiated, with low-desiring women receiving the diagnosis of FSIAD, including its “lack of receptivity [to a partner]” criterion, and men receiving the much simpler and more stream-lined diagnosis of regular old HSDD (now “Male Hypoactive Sexual Desire Disorder” or MHSDD).
Five versions of the Diagnositc and Statistical Manual of Mental Disorders (the DSM) are shown, with the most recent of them, the DSM-5, in the foreground. IMAGE CREDIT: Illinois Mental Health Counselors
These disorders and their diagnostic patterns are crucial to critically analyze, as estimates of diagnosably low sexual desire in premenopausal women currently range from around 10% to more than 25% of the population, and women receive the vast majority of low desire diagnoses.
Does this all sound very, very complicated? Well, that’s because it is—perhaps intentionally so, as a purported reflection of the complicated nature of female sexuality. The FSIAD diagnostic framework, including claims regarding neurobiologically hardwired feminine responsiveness, receptivity, flexibility, and complexity is based on an “alternative sexual response model” for women. This new model originally emerged in clinical psychology in the late 1990s, and maintains the idea that women are more sexually complex (confusing? confused?) than men. The model is applied to women only, as a so-called “woman-centric” “corrective” to the Human Sexual Response Cycle, or HSRC, originally instituted in 1966 by Masters and Johnson. The HSRC, a linear model of sexual response, posits that orgasm invariably results from sexual stimulation—or that it ought to, in sexually healthy or “normal” individuals. It has been the primary medical model of sexual response for both sexes since its inception, but the validity of the HSRC has recently been challenged by some psychologists who state that it does not accurately fit “the female experience of sex.” While a revision to the linear HSRC may indeed be timely (for everyone!), it is important to consider how an “alternative sexual response model” designed for women only and based on a categorically feminine framing of sexual health and pathology preserves the myth that women’s desire is inherently different from men’s desire, and perpetuates the notions that women are:
1.) less driven than men by spontaneous or internal sexual needs
2.) more likely than men to engage in cost-benefit analyses of sex as they consider possible non-sexual rewards or incentives to be gained from a given act (thus the shift to the language of “interest” in FSIAD)
3.) more likely than men to feel desire only or primarily when “triggered” by an initiating—and tacitly male—partner.
Insofar as it supports and is supported by the alternative female sexual response model, the FSIAD diagnosis continues to perpetuate these myths, purporting that because women are less sexual than men are by nature, a lack of spontaneous desire on its own should not lead to a low desire diagnosis for them. According to this logic, instead, it is only the women who are unable to motivate a rational, incentive-based “interest” in sex who should receive the diagnosis of FSIAD. Unlike the “unresponsive” (dare we say frigid?) woman, then, a healthy, sexually functional, or normal woman is understood to be rationally receptive and responsive to her partner’s overtures, eventually priming herself to engage in sex with him, to bring her low-desiring mind into line with her lubricated and vasocongested body. But: what of the “disordered” women who are unable to respond? Well, there are a variety of treatment modalities now available—including, most recently, daily maintenance prescription pharmaceuticals designed to change female brain chemistry.
With this long-standing tradition of framing women as less sexual and less desiring than men in mind, let’s come back to a consideration of current treatment practices. Pharmaceutical and hormonal management of female sexual dysfunction is a terrain currently being carved out further in the neoliberal marketplace. One of the most important changes recently occurred with the release of Addyi—the first FDA-approved sexual enhancement drug designed specifically for women. But Addyi is not only the first sex drug marketed to women, it is the first drug ever to target desire or libido in humans. Whereas Viagra affects (men’s) physiology only—it changes the hydraulic workings of the penis by increasing blood flow to the genital region, producing an erection in the case of so-called “impotence,” and in some cases increasing testosterone levels—Addyi affects (women’s) neurocircuitry. It goes right to the source of the so-called problem: the human—or rather the human female—brain.
But what if chemical imbalances are not the real—or at least originary—reason behind any given woman’s low desire? What if desire is actually so subjective and relational that it is impossible to isolate it in the neurotransmitters of one single individual? Sociology and gender studies researchers have examined the psychosocial, cultural, and political factors that affect desire and pleasure—and which produce gender differences in these experiences—for some time. But the quest for the inappropriately named “pink Viagra” has been one that has consumed doctors and drug-makers for the last couple of decades, after the release of sildenafil (the generic name for Viagra) and its ensuing multi-billion dollar popularity. Finding a “feminine” equivalent to Viagra has also proved a huge failure, though, as drug after drug was tested and rejected. I wonder if this is because there is no clear corollary to an erection (specifically as an erection is understood as necessary equipment for penile-vaginal intercourse) in women, or at least nothing as visible? I wonder if it’s because whereas men are understood to be natural penetrators, sexually “healthy” women are understood first and foremost as receptors? An erection can be easily managed with drugs, creating a situation in which a penis can be used for sexual intercourse. But what if desire—for both (or all) sexes and genders—is more complicated than something as easily measurable as an erection? These questions raise other important queries about what we want from sexual medicine more broadly. How do we currently assess sexual problems? How do we assess treatments? How do we know if a treatment is working? These are questions that are generally not attended to by pharmaceutical companies or even the psychologists running these companies’ drug trials, and all of their answers depend on what kind of sex we believe to be most optimal—for men, and women, to be engaging in (usually—and importantly as our sexual culture is so deeply rooted in heteronormativity—with each other).
Images on a Google search for “women’s sexual dysfunction” show either sad women alone, or women with men in a situation indicating their relationship is damaged by the changes to sexual intimacy. The editor could not readily find images from this search that involved women with other women as their partners.
The history of Addyi illuminates what pharmaceutical companies and the medical industry more broadly appear to think of these questions (or rather, not think), and attests to how stakeholders in these realms have continued to implement rigid ideas about sexual difference in regards to dysfunction and desire, making broad, sweeping claims about men’s and women’s sexuality in the process.
In the earliest years of the twenty-first century, a German company, Boehringer Ingelheim, owned the patent to the generic version of Addyi—called flibanserin. After flibanserin was shot down for approval by the FDA in 2010 and then again in 2013 (both times because the drug’s side effects appeared to outweigh any benefits to low-desiring women in clinical trials), Boehringer Ingelheim sold the rights to the patent to a U.S.-based pharmaceutical company—Sprout Pharmaceuticals. After running new clinical trials that showed slightly lower side effects but only a marginal improvement in satisfactory sexual encounters for women with low desire, flibanserin was finally approved by the FDA in August 2015. The drug was to be made officially available for public consumption in October 2015. In the interval between approval and release, before Addyi hit the shelves last fall, Valeant—a much larger, Canadian pharmaceutical company—bought Sprout Pharmaceuticals, in a $1 billion deal. Valeant is the current owner of the rights to Addyi.
So, we know that Addyi has the potential to make a lot of money for big pharmaceutical companies, but what does it actually do? Addyi is considered a norepinephrine-dopamine disinhibitor, or NDDI, when compared to other antidepressants (it was initially formulated as an antidepressant before being remarketed as a sexual dysfunction drug). This means that its mechanism of action involves allowing for more uptake of norepinephrine and dopamine, while decreasing levels of serotonin in the brain. Dopamine in particular has been found to be associated with sex drive and pleasure. According to studies conducted prior to FDA approval in 2015, women who were taking Addyi reported that the average number of times they experienced “satisfying sexual events” rose from 2.8 to 4.5 times per month. It is important to note that women receiving a placebo in the same study also reported a significant increase in “satisfying sexual events,” though—an increase of 2.7 to 3.7 times per month. Side effects were also experienced by many women who took Addyi in the study, including dizziness, nausea, fatigue, sleepiness, insomnia, and dangerously low blood pressure, particularly when combined with alcohol consumption (even just two glasses of wine).
This image shows the highlighted side effects of Addyi (flibanserin). While more are listed in the full packet, this so-called “Black Box” Warning indicates that whatever benefits Addyi may have, they certainly do not come without cost. It is not to be taken lightly. IMAGE CREDIT: Sprout Pharmaceuticals.
Despite these very real side effects, many clinicians and practitioners have vocalized their support for the drug, stating that the potential benefits may outweigh the potential harms. According to Dr. Bat Sheva Marcus of the Medical Center for Female Sexuality (MCFS) in New York City, “Drug trials have shown those women who take the drug are more receptive to sexual stimulation and have more satisfying sexual activities. I like to think of it as helping you feel your sexual hunger.” It is remarkable that Dr. Marcus makes reference to women being “more receptive to sexual stimulation” in the above quote. This again raises the question of who this drug is actually for—is it for the woman who lacks desire, and suffers because of this lack? If so, why is she suffering? Or, is it for her purportedly more virile partner (who in many cases, is male)? In a recent article in the New York Times published immediately following the FDA approval of Addyi, Dr. Irwin Goldstein, a sexual specialist based in San Diego, similarly stated that women might be willing to put up with the side effects in order to garner the benefits: “Some women might find the risk of side effects acceptable if their relationships are in jeopardy because of a lack of desire.” It seems ironic that the very cost-benefit analyses or interest schemas that women are thought to “naturally” or “biologically” engage in when it comes to sex are here being prescribed to women by doctors in the sociopolitical sphere (of which conceptions of the “natural” and “biological” are arguably a part). These prescriptions also raise important questions about gender, sexuality, and health: Why should a woman put her health at risk just to please her partner? Why is her own sexual desire so sorely lacking from this representation? Why is it assumed that what she would (or should) desire most is to make her partner happy and thus to improve her “jeopardized” relationship? What type of—and whose—health are we most concerned with here?
Further troubling is the way medical treatments for women’s low desire have been supported by financial stakeholders who brandish their arguments under the banner of “feminism.” For instance, Sprout Pharmaceuticals-funded “patient advocacy” campaign Even the Score helped catapult the drug through the FDA evaluation process, in large part by amassing a number of groups to apply pressure to the federal advisory board based on the flawed notion that the FDA’s prior reticence to approve a sexual dysfunction drug for women constitutes blatant sexism. The campaign—which includes groups such as the National Organization for Women (NOW), Sprout Pharmaceuticals itself, and a variety of so-called “women’s health” groups who received grants and other funding incentives from Sprout—has argued that women deserve access to a drug to treat their most common sexual problem (low desire), seeing as men have had a drug to treat their most common dysfunction (erectile disorder) for over fifteen years now (hence, the argument to “even the score”). Even the Score released a short “thank you” video after the FDA approval of Addyi in August 2015 (titled “#ThankYouFDA: Our First Step Towards Sexual Health Equity” on YouTube), expressing support and gratitude to the FDA for finally moving beyond their “sexist” ways and approving a drug for women. In this short clip, the male partner in an assumedly heterosexual relationship quips that the federal approval and release of Addyi might give “new meaning to his four-hour erection.” To this, his blonde, white, female counterpart responds, “I know what to do with it!” The video ends with an image of a “Treatment Score Board,” with the text “Men = 26, Women = 1.”
An image created and distributed by Even the Score, a “patient advocacy” campaign funded by Sprout Pharmaceuticals which makes Addyi and pushed for its approval by the US FDA. The number on the left represents available pharmaceutical treatments for men’s sexual dysfunction while the number on the right indicates Addyi, the first drug approved to address sexual dysfunction in women. Such imagery implies that FDA approval is a “win” for some variant of gender equality. However, not a single one of the “26” drugs for men affect neurochemistry or attempt to influence sexual desire. Instead of targeting men’s desire, they target men’s ability to maintain an erection. Addyi, by contrast, targets women’s desire, an aspect of which is purported to be their “receptivity” to their partner’s advances. IMAGE CREDIT: Even the Score
Even the Score has consistently emphasized the number of sexual dysfunction drugs on the market designed for men and compared this to the number available for women, in order to suggest that the disparity reveals a pervasive lack of concern for women’s sexual problems.
Thinking back on Even the Score’s ““#ThankYouFDA!” video—which now haunts me—I am deeply concerned about the false equivalences being made so casually about the two drugs. Just because there are drugs already on the market to treat men’s “most common sexual problem,” does that mean it will truly “even the score” to create and market drugs for women? How did we decide what men’s and women’s “most common sexual problems” are in the first place? Why do we assume they are so different from each other? Let us not forget the assumptions that are being made about men’s and women’s sexualities in each of these drugs’ design and mechanisms of action, and also in the corresponding gender-distinct disorders they require for prescription, compliance, and widespread societal endorsement. Sexual desire is not divorced from the domain of the political—how we have sex, with whom, and with what technologies (including drugs and other treatments), are all political choices. If we really cared about women, maybe we’d focus more on their pleasure, and try to dismantle some of the barriers to pleasure that women experience so regularly in our world—including childhood and lifelong sexual trauma, other forms of gendered harassment and violence, low pay, antiquated divisions of labor and disproportionate burdening with carework, with housework, with sex work, all types of exploitation, and all the other pressures that exert themselves on women (and other sexual and gender minorities) disproportionately in everyday life. Maybe we’d stop thinking about how to make women more receptive to men, and more about how to put women’s own desires and pleasures front and center. Let’s not pretend we’ve come a long way (baby), just because we now have a little pink pill to match his little blue pill. Especially not when the two pills do such very different things, and when they ultimately perpetuate such antiquated and binary narratives about what goes where and why—for whom—when it comes to sex.
As I examine this sexual marketplace and these debates wear on, I often wonder where real live women are in this mix. I wonder why we are so often occluded from the conversation when it comes to sex and sexuality—and how and why women’s desire is constantly being dissected, examined, and worked upon, but never stimulated, enlivened, and aroused on our own terms. Even more so than women’s desire, it seems that women’s pleasure has been almost forcibly shut out of the clinic and the bedroom in too many times and places, or negated in lieu of someone’s else pleasure, and that this is still the case today. In this vein, we ought to remember that sexism and misogyny are still prevalent in a variety of insidious forms—within and outside of clinical medicine and scientific laboratories, and with or without prescription drugs. The medical and scientific climate around sexuality and proposed and prescribed treatments are rather effects of a widespread and willful ignorance of women’s pleasure, and thus they represent a larger social lacuna. This is why it seems so imperative to shift the debate from the drugs themselves to the larger medical, scientific, social, cultural, and political milieux in which gender differences are configured and disseminated—configurations that have real consequences for how people experience their own bodies, other people’s bodies, and their sex lives. If taking a drug will make women feel the desire that they desire to have, and that is satisfying and pleasurable to them, then, by all means, we should have it! But let’s not stuff too many pills down our throats before seriously considering what we want, why we want it, and what we could potentially want for our futures (sexual and otherwise). There are many trajectories to that place of pleasure—if “sexual” pleasure is what we choose to pursue.
 Viagra is a drug designed to increase blood flow to the sexual organs and is targeted specifically to men, as an erection-enhancer in the case of “erectile disorder” or “erectile dysfunction” (ED).
 All of these proposed treatments were rejected by the FDA, including the oral ingestable tablet (flibanserin, or brandname Addyi) mentioned last in this list. The pill was only approved in 2015, after being shot down by the FDA twice, in 2010 and again in 2013.
 The disorder would formally be diagnosed in a woman based on her “lack of, or significantly reduced, sexual interest/arousal” as it is purportedly manifested by at last three of six criteria. One of these criteria is “no/reduced initiation of sexual activity, and is typically unreceptive to a partner’s attempts to initiate.” Here, we see how a woman’s desire to respond to her partner’s sexual advances becomes textually embedded in notions of “healthy” or “functional” female sexuality—as, according to this definition, being unreceptive to these advances signifies disorder.
 Examples include the work of Carol Vance, Deborah Tolman, Michelle Fine, Meika Loe, and many other feminist scholars. My own recent academic work has also engaged with these themes extensively; see Spurgas, 2013, Spurgas, 2016, and the authors I cite for a critical sociological investigation of women’s desire and sexuality.
 Another antidepressant, Wellbutrin (the brand name for bupropion)—which is a drug in the norepinephrine-dopamine reuptake inhibitor (NDRI) class—has been prescribed to offset the symptoms of low sexual desire and anorgasmia that often result as a side effect of taking selective serotonin reuptake inhibitors (SSRIs) like Prozac and Zoloft. In some cases, Wellbutrin has been shown to increase sexual response in women who are not on SSRIs, as well.
 There are actually only about six Viagra-style drugs (PDE5 inhibitors) on the market today. The three primary drugs consist of sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis), and the slightly different versions of these drugs. The number “26” is thus arguably an inflation of what is actually available to men. And again, it must be reiterated that all of these drugs do the same thing—increase blood flow to the penis. They are taken on an as-needed basis, when patients seek to enhance a flagging erection. Not a single one of the “26” drugs that Even the Score claims exist for men affect neurochemistry or in any way influence the vicissitudes of sexual desire.
 The false equivalence is a logical fallacy of inconsistency. It describes a situation wherein there appears to be a logical and apparent equivalence between two things, when, in fact, there is none.