Doctoring Women's Desires

Viagra turns ten this month. The Washington Post is commemorating it with an article on "Viagra for women." The whole article is interesting (though problematic in some ways), so you may want to check it out here.

Viagra for women is being defined quite differently than the little blue pills. When it works as intended, Viagra helps men with erectile dysfunction. But "female sexual dysfunction," or FSD, refers to a lack of desire - not problems with arousal. Any drug to treat a flagging libido would have to work on hormones, the brain or both. That's apparently more complicated than strategically increasing blood flow.

But isn't it simplistic to frame sexual issue so dichotomously? Is it really true that women's problem is lack of desire, while men only suffer from hydraulic malfunctions? The Post reports:

With men, all a medication needs to produce is arousal, a.k.a. an erection. A guy will conjure lust on his own. A woman, on the other hand, can get aroused -- or have the physical signs of arousal -- and remain uninterested in sex. That's why Viagra doesn't work for the ladies, even though it produces roughly the same physical effect on them as on men. (In simplest terms, the drug rushes blood to the nether regions and creates the symptoms known as "hot and bothered.")

I'm skeptical that a guy can always "conjure lust on his own." David Schnarch, author of Passionate Marriage, states on his website:

In half the couples who come to the Marriage and Family Health Center for sexual desire problems, the man is the low desire partner.

Hmmm. That doesn't sound to me as if all men are simply simmering with lust. In fact, if Viagra were a magic lust wand, you'd see a lot more of those four-hour-plus, welcome-to-the-emergency-room erections. The makers of Cialis claim it can be effective for up to 36 hours, yet I haven't read about men being plagued by 36-hour hard-ons. That's just not how these pills work. Sorry to burst your bubble, WaPo, but men's arousal still requires lust.

But what about women? According to the WaPo:

"What we know is that very little of what's going on with women and sex is below the waist," says Anita Clayton, a professor at the University of Virginia's Center for Psychiatric Clinical Research and co-author of "Satisfaction: Women, Sex and the Quest for Intimacy." "Almost all of it is above the neck."

Maybe for some women. But can I just vouch for the rest of us whose experience says that while our imagination, thoughts, and emotions matter - a lot - the sensations below our neck are equally important. (For that matter, the neck itself is a wonderfully erogenous area.) If you really think that the yummy tactile stuff doesn't matter, you're either lucky or inexperienced and never had a truly clueless lover.

Isn't it just an updated version of "good girls don't" to believe all women want from sex is intimacy? Sure, most of us want that too – but not necessarily every time, nor with every partner. Many or most of us also want pleasure.

But what's a gal to do if her libido is flagging? So far, there aren't any great solutions. A handful of promising drugs have either failed to help women (like Viagra itself) or failed to clear the FDA. Women sometimes get prescribed testosterone; sometimes it helps. The WaPo story says a couple of new drugs are in the pipeline. Let's see if they make it past the FDA.

Not everyone regards low desire as a problem. Some women and (news flash!) some men may be perfectly content with little or no desire. And if so, they won't be intrinsically motivated to take a pill to increase it. They'd first have to want to change the situation: they'd need to desire desire in the first place. And they don't. If they don't miss it, why bother?

Of course, the partners of low-desire men and women commonly see this quite differently. That's how Dr. Schnarch stays in business. Low libido can become a major stressor on a relationship. Conversely, a bad relationship will also depress desire. But the causes of low desire are chemical and hormonal, and they can't all be chalked up to relationship failures.

But does that make low desire a medical condition? And why is there a diagnosis called "female sexual dysfunction" that measures women's libido but no corresponding one for men?

The obvious sexism in this makes me agree with Leonore Tiefer, a psychologist the WaPo quotes on how the search for a female Viagra is medicalizing women's sexuality:

"Drug companies want to say to women, 'You don't need to know anything; you can have the satisfying sex life that you seek -- people dancing on TV, the whole bit -- without knowing anything. Just ask your doctor,' " she says. "I resent that, because there are specific harms that come from being ignorant and dependent in the world we live in. There may be lots of people who aren't interested in sex, but is there a medical reason for that, and do we diagnose that?"

The problem here is not merely that women's sexuality is being medicalized - that is, being brought under the umbrella of medical authority, which holds the danger that "experts" will define our desires for us. Even more, women's desires are being outright pathologized. So now we're abnormal if our desire ebbs - but we're still prone to slut-shaming if we enjoy and own up to a strong libido. Smells like another double bind to me.

But again, not everything is reducible to ideology. Millions of women are deeply unhappy about their low libido, and it's not always just due to a mismatch with their partner's libido. Often desire does a slow diminuendo over time, leaving women grieving their losses, as the WaPo story captures poignantly:

Women like Virginia, a 60-year-old native of Britain and an artist who, for privacy reasons, asked that her last name be omitted. She'd spent years asking doctors for medical help to boost her sex drive, which had once been voracious. All of them, she says, "rolled their eyes and harrumphed and tried to change the subject."

"But when I was younger, a really strong libido was just part of who I was," she goes on. "Losing that was like losing a good friend."

One of my basic principles is that we all need to take people's experiences seriously. We need to listen to what they say about their own lives, their own bodies. If we don't, we not only invite personal unhappiness (our and others'), we also risk creating social institutions that are blind to people's needs. Tiefer's critique is right, as far as it goes, but it fails to note that the issue of low desire is not just an offshoot of medicalization, it's a painful loss for many women.

If life after menopause feels anything like the months after childbirth, when hormones dampen most new mothers' desires, I can see how this would be distressing. If I'd been Catholic, I could've joined a convent during those months and not missed a thing. But it was a temporary phase, whereas Virginia can only expect desire to decline. I think women deserve a chance to get back in touch with that old lost "friend." If that comes in the form of a pill, maybe accepting further medicalization is a reasonable trade-off, just as I believe it was for oral contraceptives.

Perhaps what critics of medicalization like Tiefer and me need to focus on is not the mere fact of medicalization but the broader relationships between medicine and society, doctors and patients. If we cease to see doctors as über-experts and instead expect them to be partners in an expansive, holistic approach to health, I don't think we need to sacrifice our autonomy and authority when it comes to our bodies, our experiences. We can reject ignorance and dependence, as Tiefer urges, without being a Luddite about new medical technologies. I know, I know - that's easier said than done.

High libido kitteh from I Can Has Cheezburger?