As a feminist sex educator, promoting women’s sexual wellbeing is my reason for being. So when an FDA panel held a day-long hearing on Flibanserin, the so-called “pink Viagra,” I watched the live webcast (PDF) the way soccer fans watch the World Cup, edge of my seat, captivated.
And now the FDA is about to make a decision, based on that hearing, that has the potential to affect the sexual wellbeing of millions of women in American for years to come.
Easily the most moving part of the hearing were the heartbreaking testimonies from women who struggle with desire and want this drug — or any drug — to be approved, to help them increase their desire for sex. It’s likely that these stories are why the FDA panel voted 18–6 in favor of approval, despite, as one panelist put it, “serious, serious safety concerns” and effects that were “modest, maybe less than modest.”
A quick summary of the “less than modest” results, that the drugmaker would like us to ignore:
(1) AT BEST 15% of the women who participated in the drug trial were “responders” — that is, their desire problems were “at least minimally improved,” above placebo — while about 85% were “non-responders,” whose desire problems were not even minimally improved by the drug.
(2) On average, women on the drug had only one additional “sexually satisfying event” per month, above placebo.
Remember, this is a drug you take every day… forever. So that you can have sex one more time per month.
(3) The research participants were extremely homogenous. Here’s a partial list of women who were excluded from the study: peri- and post-menopausal women; women who had been pregnant or breastfeeding within the last six months; women in same sex relationships; and women who, within the last year, have experienced depression or other psychiatric issues that can impact sexual desire.
If you’re in any of those groups, this drug is not for you.
In short: the drug just doesn’t work for the overwhelming majority of women — and we haven’t even talked about side effects yet.
The reason it works so poorly is that the problem the drug is trying to solve — i.e., lack of spontaneous, out-of-the-blue desire for sex — isn’t a medical problem.
The heartbreaking stories women told at the hearing were not stories about living with a disease… but about living with a myth.
A lot of us grew up learning the myth that desire is supposed to feel “spontaneous,” emerging before arousal. But the last twenty years of research have made it clear that, though many people can experience desire in anticipation of pleasure, other people, at least some of the time, experience desire in response to pleasure. Pleasure comes first, and desire emerges from it. It’s called “responsive desire,” and it’s normal.
And normal responsive desire is what many women participating in the drug trial were experiencing, by the drugmaker’s own admission: FDA panel member and University of Pennsylvania urologist Dr. Phil Hanno asked why women in the study were having, on average, 2–3 “sexually satisfying events” (SSEs) per month before the trial began. If they lacked desire, why were they having any sex?
A presenter from the drugmaker explained that women have sex for a lot of reasons and that, “Once they engage in activity, it’s pleasurable.”
When he said that, my jaw hit the floor.
What the drugmaker was saying — explicitly! right to the FDA’s face! — is that they were attempting to treat healthy women. Because if you experience pleasure in the context of a mutually consenting “sexual event,” that is a normal, healthy sex life. Period.
Unfortunately only three of the twenty-four FDA panelists were sex researchers, therapists, or educators, so the panel believed the same old myth most of us were raised with — that the “urge” or “craving” is supposed to come first.
And the drugmaker has millions, if not billions, of dollars riding on everyone at the FDA — and all of us — continuing to believe that myth.
So we’re on a knife edge at the moment, with different futures awaiting us:
Imagine one year from now.
Imagine you’re a premenopausal woman in a long-term, monogamous heterosexual relationship (the only people included in the drug trial). Previously in your relationship, you experienced spontaneous, out-of-the-blue desire for sex, but these days you’re not experiencing that. Your relationship is strong, your health is good, and when you can get yourself into a sexy scenario, it goes well — you’re not just going through the motions, you actually enjoy sex with your partner — but you aren’t experiencing that urge.
So you ask your doctor about it. Is there anything she can offer to help you experience that out-of-the-blue desire?
What if your doctor says: “Yes there’s a drug that you take every day, indefinitely, that could possibly increase your sexual frequency by approximately one ‘sexually satisfying event’ per month above placebo. Also, about 10% of women experience side effects like dizziness, fainting, somnolence or nausea.”
And then she holds up her prescription pad and says, “Want it?”
How do you feel? What do you do next?
Okay. Now imagine a different scenario.
What if your doctor says: “Actually, though spontaneous desire is lots of fun and most of us grew up learning that it’s the only ‘normal’ kind of desire, it turns out that responsive desire is also normal. Responsive desire is when you don’t get that urge, but if you put your body in a sex positive scenario — for most people that means low stress and high affection — your body experiences pleasure, and desire emerges from there. Most people experience both styles at different points in their lives. Spontaneous desire isn’t a measure of sexual wellbeing. Pleasure is the measure.”
And then she holds up a booklet called something like 10 Tips for Making the Most of Responsive Desire, and she says, “Want it?”
Women are struggling. They want to feel normal and healthy in their sexual functioning, and they deserve safe, effective treatments. Fortunately, an expanding body of research has shown that sex therapy, couples therapy, bibliotherapy, mindfulness, and sex education can improve sexual satisfaction. They work more effectively, for more women, with less health risk, than any drug.
History is being made right now. If the FDA approves the drug, they pull focus away from evidence-based strategies that help women enjoy the healthy sex they are already having. If they reject it, they take us a step closer to a world where women’s sexual wellbeing has space to flourish on its own terms.
Fingers crossed. Edge of my seat.
Emily Nagoski, Ph.D, is the author of Come As You Are, a transformational new book on women’s sexuality, is stirring up a lot of conversation about the flibanserin drug which is thought to stimulate female desire, as well as the myths and lies that we are all inundated with that concern female sexuality. Available now from Simon & Schuster.