Viagra for women: over before it started

Back in 2000, Samantha Jones, the iconic sexual adventurer of Sex and the City, beds a doctor who takes Viagra “recreationally.” At that point Viagra (aka sildenafil) had been on the market for just two years in the US and was flying off the shelves. Samantha convinces her lover to let her try it, although he tells her there’s no evidence that Viagra works for women. She has the ride of her life and promptly becomes so addicted to the little blue pill that the doctor ditches her.

Fifteen years later — a year ago last month — the FDA gave the green light to the first medication for “sexual desire disorder” in women. The drug, flibanserin, went to market under the insipid name “Addyi,” more American Doll than aphrodisiac. Sprout Pharmaceuticals pimped Addyi as a pseudo-feminist breakthrough — “Meet Addyi, the first of her kind™” — but she’s proven to be anything but that. Sure, Addyi is pink and has a cute accent mark over her i, like a sassy little raspberry beret, but she’s high maintenance and has a lot of baggage. Addyi is no Gloria Steinem.

While Addyi was initially greeted with giddy enthusiasm and hailed as a “female Viagra,” the thrill faded once women read the fine print. Addyi is in no way equivalent to Viagra. Unlike Viagra, which is popped on demand and works by temporarily increasing blood flow, Addyi is a daily pill. While Viagra is a direct and precise physical solution to dysfunction — up and away, ye mighty erection! — Addyi is slow, subtle, and longer-lasting, causing shifts in a woman’s brain chemistry and neurotransmitters. It is essentially an anti-depressant and has to be taken consistently and continuously. Addyi is no “lifestyle drug,” let alone a party drug: Sprout sternly warns that Addyi is “not for use to improve sexual performance.” If Viagra is a hot one-night stand, Addyi is a long-term committed relationship.

Most significantly, Addyi has several unpleasant side effects such as sleepiness, fainting, nausea, and dizziness. Is this a libido pill or a date rape drug? These reactions are particularly likely to appear when Addyi is combined with alcohol. You read that right. What genius thought a libido pill for premenopausal American women forbidding alcohol would fly?

The FDA knows better. It rejected flibanserin twice before it finally okayed Addyi, under intense lobbying by Sprout, which disingenuously accused the FDA of gender bias. No question that women’s sexual health is under-researched and under-funded in comparison to men’s, but in this case the FDA’s hesitations had nothing to do with sexism and everything to do with risk-benefit analysis. When the FDA finally caved and approved Addyi, it stipulated that the drug had to carry a black box warning and that doctors had to be specifically trained before prescribing it.

Chances are you don’t know anyone who is taking Addyi. During the first three months it was on the market, only 1,000 prescriptions were written for it. Compare that to Viagra, which racked up 40,000 prescriptions its first week on the shelf. It’s difficult to find published accounts of anyone who has test driven Addyi, no doubt because it is not something you can take casually. A Vogue writer reported that after weeks of her Addyi regimen, she began to have racier fantasies and eventually sex with her husband became “less dutiful.” Whoo hoo! Marie Claire showcased a woman who participated in a clinical trial of flibanserin and experienced a similar erotic surge for her husband. (However, NB, her spicy tale of marital seduction involves a verboten bottle of wine.) Are you hot yet?

The clinical findings are even less sexy. The women in the main study of Addyi reported an increase of about “one sexually satisfying event per month,” compared with those taking a placebo. Men get erections on demand and women get “one sexually satisfying event per month.” This is progress?

Brass tacks: what exactly is Addyi supposed to be treating? According to Sprout, it is combating “acquired, generalized” HSDD: that is, “hypoactive (low) sexual desire disorder.” Addyi’s makers describe HSDD as “low sexual desire no matter the type of sexual activity, the situation, or the sexual partner,” and that has no physical/medical cause and is not related to “problems in the relationship.”

Many prominent feminist health advocates, including Leonore Tiefer, Betty Dodson, and Emily Nagoski, called HSDD BS before and while flibanserin was in trials. Nagoski, author of Come as You Are and thedirtynormal, writes that “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.” Nagoski points out that HSDD pathologizes the immense range of ways in which women are turned on — for example, “responsive desire,” in which women need stimulation to start the arousal process, versus “spontaneous desire” à la the horny vixens of pornography. Reading the description of HSDD on Addyi’s information page, one can imagine numerous options to try before starting a woman on a daily dose of brain chemistry altering flibanserin. Foreplay. A vibrator. A racy book or video. A new lover.

Addyi is just the latest chapter in the long story of women’s sexuality being treated as a medical problem. Some bogus theories had ironic benefits: the late nineteenth century treatment of women’s so-called “hysteria,” for example, entailed vaginal massage and vibrators. Other ideas have been downright damaging, such as the notion that “vaginal orgasms” are superior to clitoral ones (thank you, Freud), or that women’s libido needs to be kept in check by clitoridectomy.

The condition Addyi is supposed to treat (HCDD) is spurious and arguably trumped up to benefit pharmaceutical companies. The day after the FDA approved flibanserin, Sprout Pharmaceuticals was bought by Valeant Pharmaceuticals International for one billion dollars. Valeant promptly jacked the price of Addyi to $800 a month, causing many insurance carriers to drop its coverage. Stock fell, Valeant cut sales reps, and Addyi’s original CEO left the company. A report card issued by a consumer advocacy group on the one-year anniversary of Addyi’s approval gave it Ds and Fs. The story of Addyi is in part a familiar one — greedy big pharma does the consumer wrong (see Martin Shrkreli and the EpiPen debacle) — but there’s an added element of exploitation.

The big puzzle here is why women’s sexuality, despite three waves of feminism, is still subject to so much confusion. (Let’s be clear: men’s sexuality is also complicated. But it’s not mystified and moralized about to the degree that women’s sexuality is.) Judging by the initial titillation around the idea of “female Viagra,” there is considerable interest in a drug that would ignite women’s sex drive, amp up a flagging sex life, or boost intensity and pleasure. Some women might see a libido drug as a gateway to what Erica Jong described as “the zipless fuck,” in her 1973 novel Fear of Flying: sex without any strings attached. Addyi is not that drug.

It’s worthwhile to consider HCDD alongside the findings of contemporary female sexologists. According to Daniel Bergner’s 2013 book on the current state of female sexology, What Do Women Want? Adventures in the Science of Desire, women (of any orientation) have a much wilder libido than men. They can get turned on by a much wider range of images, fantasies, and ideas than men. However, there seems to be a disconnect, for most women, between what turns them on and what they actually do in their erotic lives. This research suggests that cultural conditioning plays a far bigger part in women’s sexual experience than anatomy does.

Most of Addyi’s opponents argue that the way to improve your sex life is education, not medication. Discover what turns you on, and then make it happen. It sounds simple, but the statistics about women’s reported levels of sexual satisfaction suggest that otherwise. Not that orgasm is the gold standard of pleasure by any means, but Elisabeth Lloyd (The Case of the Female Orgasm) estimates that 11 percent of women have never had an orgasm. Far more are failing to achieve them through sexual practices that simply don’t stimulate the clitoris. (Surprise surprise: lesbians report a higher rate of orgasm than heterosexual women.) One of the most chilling scenes in Liz Canner’s 2009 documentary Orgasm Inc.: The Strange Science of Female Pleasure, is one in which a woman has electrode wires threaded through her spine in the pursuit of a climax during intercourse with her husband. She has no problem coming through other means.

Bottom line: Addyi is not a libido drug. It’s an anti-depressant, which might, as a benefit, increase a woman’s interest in sex, but that has a low success rate and carries a lot of risks. The most distressing part of the Addyi story is that women’s best interests aren’t being addressed. Women should have access to recreational sex drugs, just as men do. But for now, for most women, the medicine cabinet is the wrong place to look in the pursuit of pleasure.