It may (or may not) surprise to learn that hypoactive sexual desire disorder (HSDD) the “disorder” treated by the new drug Addyi didn’t exist before 2004. Why in 2004 did we decide that normal female sexual response was a condition? Well, HSDD was established/invented/introduced by industry to prepare the market for a testosterone patch for women.
If you have a drug that can produce a specific outcome but that outcome doesn’t address any known condition the next step is medicalize normal. It’s not much different from telling people cocaine is an option for hypersomnia defining hypersomnia as needing 7-8 hours of sleep a night and waking up refreshed.
While HSDD has now been removed from the psychiatric lexicon and our understanding of the normal female sexual response has evolved the damage was done. While testosterone never made it past the FDA (one of the sticky issues being the increase in breast cancer), flibanserin, now known to the world as Addyi, ran the gauntlet successfully the third time being the charm.
After the drug failed the second time Sprout launched a very aggressive campaign called Even The Score that promoted the idea that HSDD is very common (almost half of women have it!) and that doctors are terrible at diagnosing HSDD (I will defend my profession and say that it is hard to diagnose a condition that doesn’t exist). The message, once the pseudo-feminism is stripped away, is clear – if a woman doesn’t want to initiate sex regularly with her partner (never mind if once initiated she very much enjoys it) then she must have a disorder.
Getting woman on board is obviously essential if the FDA is giving you the cold shoulder. You need their advocacy, but as a drug company you can’t have doctors telling women who complain about a unfulfilling sex life that perhaps there is a relationship issue or a depression issue (depression affects sexual interest) or that receptive libido is totally okay and normal, you also need doctors to buy into the medicalization of normal. To do this, long before your drug is approved because you want doctors primed to prescribe, you develop Continuing Medical Education (CME) programs.
Doctors have to do a certain number of CME activities to maintain their license and so this is great venue to plant the seed that the next time a woman presents in distress about her sex life instead of spending the time explaining that having a spontaneous libido 100% of the time doesn’t really fit with our modern understanding of the female sexual response, and screening for depression, and asking about other medications that can affect sexual response, and screening for pain with sex, and taking the time to listen to the problems at home you can just give them a pill and send them out the door! Not because giving them a pill is easy, no sir, because giving them a pill is right thing to do medically!
A paper published this year in the Journal of Medical Ethics found 14 such CME activities, six of which were on Medscape. The CME activities all presented medically dubious claims about HSDD such as:
- Hypoactive sexual desire disorder is very common and underdiagnosed
- Hypoactive sexual desire disorder can have a profound effect on quality of life
- Women may not be aware that they are sick or distressed
- Hypoactive sexual desire disorder and distress can have other names (a lout of a spouse was not one of them)
- Clinicians need tools and resources to help them diagnose hypoactive sexual desire disorder
- Simple tools, including the decreased sexual desire screener (DSDS) and Female Sexual Function Index (FSFI) can assist clinicians in diagnosing hypoactive sexual desire disorder
- A major barrier to clinicians talking about hypoactive sexual desire disorder/female sexual dysfunction is the lack of medications
- It is problematic that there are medicines available to treat sexual problems for men but not women.
And the financial disclosures of the doctor who is the expert for this particular CME program:
These CME programs are very concerning. The authors of the article in the Journal of Medical Ethics point out that a “study conducted by Pri-Med, a medical education and communication company that is a vendor to industry, found that live CME activities funded by Boehringer Ingelheim on hypoactive sexual desire disorder increased the percentage of primary care clinicians who indicated that they would screen for hypoactive sexual desire disorder.”
This bears repeating. The tactic of getting doctors to buy into the medicalization of normal via industry funded CME is effective.
We all know pharma reps bend the truth, but CME programs written by experts and sponsored by respectable institutions surely those are completely legitimate. After all, the educational grant was “unrestricted.”
Here is the breakdown of sponsors of the 14 CME modules identified in the article (sponsor is who arrange the CME credit):
- Medscape, six
- Baylor College of Medicine, two
- Journal of Family Practice, one
- Journal of the American Academy of Physician Assistants, one
- American Society for Reproductive Medicine, one
- The University of Massachusetts Medical School, one
- U.S. Psychiatric and Mental Health Congress Conference and Exhibition (2009), one
- Cmecorner.com, one
I also found one from Omnia that appears not to be mentioned in the article and this one is complete with a patient handout (why even talk with her when you can give a handout!) that perpetuates the lie that HSDD is a common disorder.
So there you have it. Industry can convince doctors that doing the right thing is to medicalize the normal female sexual response and then to prescribe for it.
I have been asked many times by patients in the past few years about flibanserin. I take the time to explain the female sexual response, using the diagram below that I have now put in so many posts. I explain to women that being horny all the time isn’t the “natural” state and that what they or their partner see on television or in movies or in porn is fantasy. I explain that it is normal to have times in your life where your spontaneous libido ebbs and flows, but as long as you have emotional intimacy with your partner and once sex is initiated you find it pleasurable then everything is okay. Every single one has seemed shocked and relieved to hear that they are completely normal. Explaining female sexual response to my patients is not time-consuming, it takes less than five minutes. But even if it were time-consuming it wouldn’t matter.
It is tragic and shameful that the message that a woman is somehow sexually broken if she don’t feel “sexual desire for about 50% of her waking hours” has not only received a stamp of approval from the FDA, but has also found its way into our continuing medical education system, which apparently seems to function very effectively as Big Pharma’s lap dog.
Women deserve the best medicine, not lies about their sex life designed to make them feel bad so they take a drug.
Dr. Jen Gunter 
I find the industry’s focus on HSDD laughable. Especially when vaginal atrophy is a real source of dysfunction for many, many women and there is precious little women can do about it if they aren’t eligible for hormonal remedies (i.e. breast or ovarian cancer survivors). I wonder what could have been accomplished for women if all the time and effort on a fake disorder would have tackled a real sexual health problem.
Almost half of all women also suffer from Incompetent Foreplay Disorder (IFD) and Husband Not Helping with Housework Disorder (HNHHD).
Since this substance does not correct any known physiologic defect, how is it different from any other recreational drug such as Ecstasy? Both compounds would interact in the brain to alter mood and pleasure seeking. Neither would be fully understood from a molecular point of view. I’m surprised women would be enthusiastic about big pharma manufacturing a condition so it could manufacture a drug so that it could enrich itself at their expense – both financially and medically.
The bit that makes my hair stand on end is the bullet point ‘women may not be aware that they are sick or distressed’. That sounds entirely too much like denying a woman’s own experience of her body…
That’s what I thought, too. You put it into words well.
Interesting. To me (layperson) it seems it would go without saying that desire isn’t constant. Life activities and stresses and happiness levels are not constant, either. Sense of emotional closeness to partner is not constant. Responsibilities to/for family members and work and volunteer activities … and so on. And even feelings of attractiveness/desirability change through time. Big, unexplained changes in desire are worth checking on, though.
Thanks, Jen. I don’t think this applies to all doctors, but some. And the media of today blasts women with ideas that just aren’t true. And taking another pill? When are we going to learn that life is less complicated when we can make changes in our lives without taking another pill–of course unless it’s absolutely necessary.
I hear of lots of women using testosterone so I’m doubtful. But I hope I’m wrong!