Making The World Safe For Low Desire

All the recent celebration in smart sex-activist circles about the FDA refusal to approve the proposed Flibanserin drug for increasing female desire has left rather a sour taste in my mouth. But there isn’t a lot I can say about it, because most of the celebration is coming from people who are smarter and better informed than me on these sorts of issues. I was just developing a general sense that folks were not so much against the drug itself as they were opposed to the idea of a drug for female desire. And at that, my anarchist soul revolts. Don’t like that idea? Don’t take the fuckin’ drug. No pun intended.

Picking at random one of the celebrants, Emily Nakoski, whose smartness I revere and who has surely forgotten more about sexuality than I may ever hope to learn, I’ll post the most specific criticism I saw her make of the drug itself:

The drug, now seeking FDA approval, is basically an antidepressant that you take every day. Would you take a pill every day for 6 months in order to have a 15% chance of experiencing “meaningful improvement” in your level of sexual desire? And then do you have to take it for the rest of your life?

I’m pretty sure Emily intends those questions to be rhetorical, and expects that the answers should be negative. I hope and trust she’ll correct me if I’m wrong. Meanwhile, I forge onward. Remember I’m an anarchist, without much use for the FDA drug approval process, because I believe individuals are capable of making informed medical decisions for themselves, in consultation with their medical professional of choice. In light of that, allow me to tease out the arguments against the drug that I think Emily has encapsulated in that one statement plus two rhetorical questions:

• It’s some heavy shit to be taking;
• It takes a long time to find out if it’s working;
• The chance of it working is pretty low;
• If it works, you’ll need to be taking that heavy shit for as long as you want the benefits.

What I don’t see in that is any reasons to have a federal agency declare a priori that nobody ought to get the right to decide for themselves whether those costs outweigh the potential benefits.

But I’m just a schmoe with a blog. Hence my interest in seeing Marty Klein’s post this morning: Flibanserin Defeated; What Is Accomplished?

Marty writes:

The big news in the world of sex is that Flibanserin, the drug that’s supposed to increase desire in some pre-menopausal women, has been rejected by the federal Food & Drug Administration (FDA).

A group of activists is taking credit for pointing out the drug’s side effects, limited efficacy, and big-ticket marketing campaign. They also criticize the medicalization of female sexuality, accusing drug maker Boehringer-Ingelheim (B-I) of creating a disease where none exists.

Despite clear evidence that the lobbying had no serious impact on the FDA process, these activists are now celebrating, having made the world safe for, um, low desire.

But what’s really been accomplished?

* The further public confusion of desire and arousal. People everywhere are referring to “pink Viagra,” which is a fundamental error.

Viagra addresses arousal, not desire. Flibanserin addresses desire (albeit imperfectly), not arousal.

* Reinforcing the myth that women’s sexuality, especially desire, is more complicated than men’s.

No, no, no. Eroticism in adults is complicated, and it insults both genders to suggest that only women have emotions around sexuality. Professionals don’t understand why men don’t desire women they love any more than we understand why women don’t desire men they love.

Most men are not heartless machines eager to screw anything with a heartbeat, any more than most women are frigid creatures who only acquiesce to sex out of duty.

* Denigrating the idea that some women (and their relationships) really do suffer from low sexual desire even when the emotional and relational conditions are supportive.

It’s accurate, of course, to say that there isn’t a single level of desire that’s “normal.” But women who experience dramatic drops in their desire know there’s something wrong. And isn’t it obvious that one definition of “healthy adult” is the experience of sexual desire when the conditions are right?

* Knocking down the straw man that “women’s sexuality is so simple it can be fixed with a pill.”

C’mon, no one–certainly not the drug company–has suggested this. Flibanserin is proposed for women whose reduced desire can’t be explained by a dozen other factors, including well-known desire killers such as ambivalence about the relationship, sexual trauma, and husbands who don’t bathe.

I’m not the only one, it seems, who thinks the activist-celebrants were arguing against something other than the pill in question.

But the ranty part of Marty Klein’s article is where things really start to get good:

There’s something unseemly about activists–self-described feminists, sexual health advocates, whatever–working so hard to prevent a drug from coming to market because its creators might manipulate and confuse possible consumers.

I didn’t hear much about this when Viagra was cooking (actually, I wrote one of the few cautionary articles about this back in 1998). I still don’t hear much about how Viagra exploits people’s over-emphasis on erection as a prerequisite to enjoyable sex. Is that sexism?

And I don’t like the idea that we have to protect women from being told by a drug company that their sexuality is problematic. Women–people–are told every day that their sexuality is problematic, by beer commercials, Cosmo magazine, Dr. Phil, and priests.

Millions of women (and their partners) know their lack of sexual desire causes suffering. Whether taking a drug is the best treatment for any woman isn’t the point. Dismissing B-I’s drug and its marketing as “disease mongering” is terribly disrespectful to the many women who struggle with low desire.

The vociferous righteousness about this drug is terribly reminiscent of the hysteria over other sex-related drugs such as Plan B, RU486, and gardasil. Historically, conservatives have always attacked any technology designed or used to support sexual expression. But getting this resistance from progressives who care about women is new.

So with Flibanserin’s defeat, I don’t want to hear about the “patriarchal drug companies” who are “willing to develop a drug to help men, but cruelly withhold one from women.”

I share Marty Klein’s surprise at seeing progressives who care about women lining up with the sexual hysterics against a potentially-helpful sexual technology. It may not be very good technology, and it’s clearly not for everyone, but shouldn’t the decision whether to use it be between — to use a phrase that may have certain resonances — a woman and her doctor?

Let’s go back to Emily Nagoski for a second. Right after those two rhetorical questions I quoted above, she wrote:

If you’ve experienced a big ol’ drop in your desire for sex and you want your desire for sex to come back, talk to a sex therapist. Sex therapy helps people.

Sounds plausible to me. Sounds sensible. Of course, I know nothing about sex therapy; for all I know it could consist of naked tarot card readings conducted by a talking horse. But presumably it’s respectable stuff that works, because Emily’s smart and knows about this stuff and I trust her opinion and she offers it up right after casting aspersions at a drug that she says only works maybe 15% of the time. So sex therapy must be better than that, I guess.

On CNN they call what I’m doing now the battle of the experts, because I’m shoving the camera back in Marty Klein’s face. He doesn’t get specific, but he doesn’t sound quite as sanguine:

And complaints that the drug would create unrealistic expectations in consumers–doesn’t sex therapy do that, too? Most people don’t realize we do so poorly enhancing our customers’ sexual desire. A typical outcome is that people acquire better communication skills–not more reliable desire.

Fortunately for sex therapists (and the public), no one’s trying to prevent the public from getting access to us. Or demanding data on the effectiveness of our treatments. If people saw our numbers, I don’t think the public would ever trust us again.

And we cost more than a pill–sometimes with side effects that are just as complicated.

Aphrodisiacs Closer?

As I headed into the office on the morning of this recent Friday the 13th I had an intuition that interesting news would await me. It did, in the form of a headline on Bloomberg: “Desire Drug May Prove Sex Really Is All in Her Head.” Sometimes the news gods are kind.

The gist of this story is that the German pharmaceutical firm of Boehringer Ingelheim GmbH, needing a new revenue source to make up for those which is likely to lose when its patents expire on Mirapex and Flomax, surveyed a large number of women over 18 and discovered that among many of them, ebbing sexual desire was seen as significant cause of distress. Boehringer’s answer has been to begin trials of a new drug called flibanserin, which by blocking serotonin and triggering dopamine production is supposed to amp up the libido. Boehringer is supposed to be presenting results at the upcoming meeting of the European Society for Sexual Medicine, starting Monday.

A big win, perhaps? Humanity has sought aphrodisiacs since it climbed down from the trees. The big difference is that we might just be closing in on ones which can be clinically proven to work, with all the fun that might entail.

But of course, these moves are controversial. The problem seems to really stem from an annoying distinction between therapy and enhancement uses for drugs. Many people believe that it’s okay to use drugs to treat “illnesses” or restore “normality,” but not to use them to just enjoy yourself (or make yourself smarter, stronger, etc.) So advocates of drugs like these are forced into the dodge of claiming that they exist to treat something called “Hypoactive Sexual Desire Disorder.” Critics can then point out that there is no universally (or perhaps even generally) accepted standard for what the “right” level of sexual desire is, and further that there’s something a little nasty about stigmatizing people with the “wrong” level as somehow pathological and in need of treatment. On one version of this view, hypoactive sexual desire disorder is just a made-up condition to allow Boehringer to sell drugs and make money.

My own view, for what it’s worth, is to acknowledge that the critics may have a point but then to ask whether we should care that much. Why should we rely on men in white coats to tell us what the “right” level of sexual desire for us. Shouldn’t we deliberate for ourselves and make our own judgments about what degree of sexual desire will make our lives go well and, having so deliberated, aren’t we entitled to have our judgment respected? (Reflections like this one show just how coercive and illiberal the therapy/enhancement distinction potentially is.) Shouldn’t we decide for ourselves whether our sexual desire should be enhanced or, for that matter, reduced if it so suits us, without having to pretend we’re suffering from some sort of disease?

Of course, I would also offer a caution here, to the effect that perhaps what we really want to enhance is not desire but pleasure. If you think about it enough, enhancing just desire by itself is a peculiar goal. Wanting is not the same thing as liking, even if the two are often intimately connected. Having stronger desires could be a positive problem if you lack the means to satisfy them — you might just be letting yourself in for a more frustrating life rather than a more fulfilled one. And perhaps satisfaction of desire isn’t really all that great just by itself and unaccompanied by the right hedonic state. Haven’t you ever fulfilled a great desire in your life only to feel at least somewhat disappointed in the end? It seems more plausible to think that it’s the hedonic state itself that matters: isn’t it wonderful when something happens to us for which we had no antecedent desire (perhaps because we did not even know it existed before experiencing it) but which was a source of joy when it happened (a major point in favor of skilled lovers, yes?).

Though of course, I see no reason to think that flibanserin or other future additions to the pharmacopoeia won’t also enhance pleasure. If so, good times ahead.