Sprout Pharmaceutical is again asking for FDA approval for flibanserin, a pill that they say will help women experiencing low levels of sexual desire. In a New York Times op-ed, sex educator Emily Nagoski is skeptical:
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.
No, no, no. This is an argument I really want to die. I don’t mean to pick on Ms. Nagoski, but there’s no need to get hung up on whether something is a disease when investigating drugs that change it. That’s an approach that will lead to pain, heartache, and possibly jail time.
Here’s the issue that has her concerned:
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.
To my inexpert ear this seems like a plausible bit of psychology, and since Emily Nagoski is a credentialed expert on human sexuality, I’m sure she knows a lot more about female sexuality than I do. [Insert self-deprecating joke about not understanding women here.] And what she’s talking about should probably be a very important consideration for any woman thinking about taking a pill like this.
However, just because something is normal or natural doesn’t mean we shouldn’t change it. About 20 years ago, there was a major controversy over the safety of silicone breast implants, and the FDA was stepping in to regulate them. Virginia Postrel of Reason magazine wrote an editorial about that which has stuck with me over the years, and which seems relevant here:
Something different is going on with breast implants: They are frivolous, and they are biological. They are overt attempts to overthrow nature, to use the mind to reshape the body, to alter genetic destiny without giving a good reason. They are not “vital needs,” like fibers, key boards, or electricity.
Traditional medicine and its regulatory progeny disapprove of risks, except to restore what’s “normal.” When cosmetic surgeons tried to define flat-chestedness as a disease–the better to cram breast augmentation into the healer paradigm–they looked like manipulative fools. Their article became a smoking gun to feminists who saw implants as a patriarchal plot. But the very attempt shows what’s “wrong” with implants in the eyes of the law: They’re designed not to fix a disease but to improve what’s normal. Repair is OK; improvement isn’t.
This bias against changing things that are normal is complicated by the fact that we have a history of deciding or discovering that things previously considered normal are in fact subject to medical intervention. Humans have presumably had allergies forever, but we only really began to recognize them as such about 100 years ago, and we now have a lot of different treatments. It’s natural for our eyes to lose their ability to focus clearly as we get older, but nobody suggests that people getting Lasik eye surgery would be better off accepting their “different way of seeing.” We used to think that even severe dementia was just a normal part of getting old, until we identified Alzheimer’s disease. Now instead of just accepting the decline in mental function, we’re working on treatments.
Or what could be more normal than childbirth? And yet we spend millions of dollars on contraceptives to prevent it. Except for women experiencing the perfectly common problem of infertility — they spend millions of dollars on drugs, treatment, and IVF to get pregnant. We’ve also found ways to reduce the natural pain of childbirth. All of these improvements on nature were highly controversial when they were first introduced. But we got used to them.
Nagoski is concerned that women will feel pressure to take a pill they don’t need:
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.
There’s certainly a history of women being pressured into dubious ways to “improve” themselves, from high-heeled shoes to corsets to cosmetic surgery and unnecessary hysterectomies, so any women considering any kind of medical intervention should do her research. And I can understand the the need for the thoughtful exploration she describes (there’s more detail in her article and on her blog), but she goes too far when she argues against any medical treatment.
The efficacy of flibanserin is in question, and it may have some troublesome side effects, so I could understand why she’d recommend against that drug in particular, but Nagoski objects to the idea of using medicine to change how sexual desire works. This comes way too close to some of the “purity” arguments that have been used against psychoactive medications over the years.
Depression is another one of those treatable conditions that used to be considered normal. When depressed people weren’t being asked “Why can’t you just cheer up?” they were being told to live with it and things will get better. They were told that plenty of depressed people manage to live successful lives, and that they should learn to accept themselves as they are. Just keep soldiering on. Suck it up. None of this was really very helpful. In all fairness though, there weren’t any better alternatives.
That changed with the invention of antidepressants, especially with the modern drugs that affect neurotransmitters such as serotonin, dopamine, and norepinephrine. (Flibanserin acts on those neurotransmitters as well.) They’re not always effective, and they can have side effects, but when they work, they can greatly improve the lives of people suffering from depression.
And yet people taking antidepressants are still told by well-meaning friends and family (or even strangers) that they should try to fight depression in other ways — eat better, exercise more, meditate, find a hobby, get out and meet people, try to look on the bright side — rather than “depending on a drug to make you happy.” This often comes with a sizable dose of smugness: “Look at me, I’m happy, and I don’t take drugs.”
There’s also been a general backlash against the market success of antidepressants, with a lot of whining about the number of people on Prozac, the “over-medication” of American society, and the way big pharma is pushing their drugs on us by getting everything classified as a disease. I’m sure there’s been some of that, especially with captive populations like school children, where I’ve heard accusations that ADHD is over-diagnosed. On the other hand, if your child gets the drugs and the quality of his life improves, how much does it matter if he really had ADHD or was just fidgety?
Some of the reaction against pharmaceutical solutions seems to have its origin in the same anti-drug prejudice that fuels the War on Drugs — the attitude that using drugs for anything other than treating a disease is evil. This is why someone with a diagnosis of ADHD or narcolepsy can get Adderall from Walgreens, but college students trying to study harder have to order it from sketchy online pharmacies in Hong Kong. And when factory workers on long shifts use methamphetamine (essentially the same drug) we call them meth addicts and put them in jail.
Apparently we still haven’t learned our lesson about what happens when we pathologize normal sexual functioning.
In one extreme example, medical professionals once took seriously the idea that homosexuality was a disease in need of a cure.
[…] 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.
Let me respond by describing another human sexual aspect that is currently treated as a disorder: Gender dysphoria. Some men aren’t happy being men. They’d rather be women. We could tell them that being born a man is their fate and they better straighten up and act normal. Or we could tell them that lots of people have gender identity problems and learn to live with it. We could even tell them to settle for wearing wigs and makeup and women’s clothes.
But as it turns out, we have at least a partial “cure” for being male. We have hormones to change their fat distribution and enlarge their breasts. We have lasers and electrolysis to remove unwanted hair, and we have dermabrasion to smooth their skin. We have surgical procedures to reduce their adam’s apple, change their voice, enlarge their breasts, and change the shape of their face, hips, buttocks, and genitals. Half the people in the world are male, and there’s nothing wrong with that. But some of them don’t like it, and within the technological limits of our civilization, we offer them the ability to change.
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.
And Emily Nagoski is in danger of making herself part of the long history of telling people they should learn to live with things they don’t like.
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.
I suspect that this is good advice. But there’s a difference between advice and policy. The FDA isn’t about giving advice, it’s about controlling what medications are available. There’s a difference between giving women the information they need to make an intelligent choice and giving the FDA the power to take that choice away.
Let me quote Virginia Postrel again:
The debate over breast implants is only incidentally about the venality of lawyers or the benefits of a C cup. It is about who we are and who we may become. It is about the future of what it means to be human.
The debates about flibanserin, like the debate about breast implants, is about whether or not women get to have control over what they want to be.
(Hat tip: Maggie McNeill.)