Flibanserin Sparks Debate About Women And Sexuality

(Illustration: Robert A. Di Ieso, Jr.)
Jun 05, 2015 at 1:22 PM ET

There is a feminist narrative at play among researchers who believe that mainstream thinking about female desire is all wrong. Some of these experts worry that a so-called “female Viagra” pill will distract from the important task of revolutionizing the way we view women’s sexuality. A select few even argue that instead of a pill, many “low desire” women need only to re-imagine what normal desire looks like.

In popular consciousness, desire is thought of as something that arises spontaneously. You’re washing the dishes or checking your email and suddenly, inexplicably, you start jonesing for sex. But many researchers believe that instead of necessarily happening out of the blue, desire often happens in response to arousal. You’re bloated after a big meal and feeling not the least bit sexy — I dunno, I’m just imagining that happens to people who are totally not me — but your partner touches your neck in just the right way and you find yourself, inexplicably, wanting sex. This is what’s known among researchers as responsive sexual desire: it arises in reaction to something. From this perspective, there’s nothing wrong with women who rarely, if ever, find themselves randomly overcome by an urge to have sex.

Emily Nagoski, a sex educator and author of “Come As You Are: The Surprising New Science That Will Transform Your Sex Life,” is one of the experts who believe that education about responsive desire could do more good for women’s sexuality than any pharmaceutical. In fact, she says that the approval of such pill would be a “set back” for these attempts.

“It would slow down the progress of building a more evidence-based cultural narrative around women’s sexual functioning,” she said. “People are going to flock to the pill in droves. If they knew that they were healthy, they would actually be healthy in this weird, ironic way.”

The Food and Drug Administration on Thursday backed the female libido drug flibanserin. The drug’s proponents are no doubt celebrating the decision as a win for womankind — after all, Terry O’Neill of the National Organization of Women attributed flibanserin’s previous two rejections by the FDA to a pervasive cultural attitude that prizes the sexual health of men over women.

Psychologist Lori Brotto, who has done extensive research on female desire, thinks there is potential for flibanserin to distract from important cultural conversations about female sexuality. “There were at least four of the [FDA] panelists who said women desire better than this medication,” she said, noting that they were probably referring to the marginal affects of the drug. “But I think taken a different way, women deserve better in terms of recognizing that their desire is so much more than two items on an FSSI.” She’s referring to a Female Sexual Subjectivity Inventory, a theoretic model for measuring women’s sexual self-perception that also addresses desire.

Although flibanserin is often referred to as “female Viagra,” it works entirely differently. Unlike the blue pill, which increases blood flow to the genitals and is taken only as-needed, flibanserin targets the central nervous system and is taken every day. Over time it alters the balance of chemicals in the brain, in a fashion not unlike what you see with antidepressants. More technically, it boosts dopamine and norepinephrine, which are tied to sexual excitement, while regulating serotonin, which is linked to sexual inhibition. This, its supporters say, increases women’s desire.

Some critics argue that the emphasis on pharmaceuticals to solve women’s sexual problems is a result of projecting a male model of spontaneous desire onto women. “We tend to think that male desire and female desire should sort of look the same,” said Ian Kerner, an author and sex therapist who frequently sees women with complaints of low desire. “Maybe that’s because in the infatuation stage of romantic love, we often can’t keep our hands off of each other and it feels like sort of desire is matched for desire.” But that “neuro-chemical cocktail,” as he calls it, soon wears off and desire between the sexes often begins to look very different, he says.

Indeed, one study found that 74 percent of men experienced spontaneous desire, while 2.5 percent had responsive desire. Compare that to another study which found that just over 30 percent of women primarily experienced responsive desire. There is disagreement on just how real this gender divide is, though. In response to a New York Times Op-Ed Nagoski wrote about responsive desire, she says she heard from three times as many men as women who wanted to thank her for articulating their experience. “That made me wonder if the cultural narratives around men’s and women’s desire have skewed the way men and women answer survey questions about desire,” she told me.

Debby Herbenick, a sex researcher at the Kinsey Institute, suspects that responsive desire is a useful model for everyone. “Most likely, both women and men sometimes experience their desire as responsive and sometimes experience it as spontaneous and much of the time, it’s probably difficult to tell in the moment which is which,” she said. In other words, it’s often a chicken-or-egg situation: Which came first, the sexy wants or the sexy thoughts?

Nagoski goes so far as to rule out the existence of spontaneous desire entirely. “No desire is ever spontaneous, literally,” she said. “It just feels spontaneous for some people because it crosses the threshold into awareness before they’re aware of being physiologically aroused.”

Our understanding of desire as a simple, linear process can be traced all the way back to 1966, when William Masters and Virginia Johnson published their groundbreaking book, “Human Sexual Response.” From their laboratory observations of people having sex, they proposed a four-stage model for sexual response: excitement, plateau, orgasm and resolution. In the 70s, sex therapist Helen Singer Kaplan proposed a simpler formula: First comes desire, then arousal and then orgasm. That is still the dominant cultural understanding of how both male and female sexual desire work (although a Vocativ analysis found that in forums for women with low desire, it’s not uncommon to see women promoting the idea that there is great variation in what constitutes “normal” female sexuality). That is despite a large body of research supporting another scenario entirely.

Researcher Rosemary Basson in 2000 coined something known as the circular sexual response cycle, which proposed that female desire functions in a circuitous rather than linear manner. She suggested that women experience the urge to engage in sex for a number of reasons, not just from a spontaneous aching in their loins. In the 15 years that have followed, researchers have tested her theory and, supporters says, built a a body of evidence for it. Now, the concept has largely been mainstreamed — at least clinically. “I travel all over the place and work with family doctors and physicians who work with women with sexual problems and singlehandedly they say this is the most useful therapeutic tool that they have, which is there ability to sit down with a woman and explain the model,” says Brotto.

This thinking around what normal desire looks like led to a significant revision in 2013 to the Diagnostic and Statistical Manual of Mental Disorders. The low-desire condition flibanserin is meant to treat, hypoactive sexual desire disorder, was taken out of the manual, at least as it applied to women. It was replaced with female sexual interest/arousal disorder in an attempt to acknowledge the way desire and arousal are often difficult for women with sexual dysfunction to disentangle. “The [old] definitions were very much based on a more male-based conception of what sexual functioning is,” said sex researcher Meredith Chivers. “The revamping was really about looking at these phenomenon through a gendered lens.”

The general concept of responsive desire — at least as a way, perhaps not the way, that people experience sexual desire — has widely been accepted among researchers, although there is still controversy. “I don’t think there is a consensus,” says Chivers. “There is actually quite a lot of division in the field about these ideas.” For example, a study earlier this year found that more women identified with the linear models of desire than the circular one; although Brotto says the researchers misrepresented the concept of responsive desire. Some have argued that the responsive desire framework is actually, well, kind of rape-y. Take psychiatry professor Anita Clayton’s essay last month in the Huffington Post: “What these people are REALLY saying is that a ‘no’ from a woman when it comes to sex might not really mean ‘no’ if her desire is going to kick in anyway,” wrote Clayton, who has consulted for flibanserin’s maker, Sprout Pharmaceuticals. “Think about that for a second.” Brotto says that’s an “inaccurate and potentially dangerous” message, and one she would never endorse.

These competing movements have really only encouraged each other, though. “At the same time that we’ve gotten more and more research showing that responsive desire is normal, that has also been the time that the medicalization, the search for a pink viagra, has escalated,” said Nagoski. She argues that these two movements have coincided because the search for a female libido pill “has increased interest in funding for research around women’s sexual functioning.” But she says that makes the research and activism around responsive desire feel “more urgent” — and this FDA recommendation only more so.