GRSJ224/medicalization of female sexuality

Medicalization of Female Sexuality

The medicalization of female sexuality is the process by which female sexuality has come to be defined primarily through a biomedical model that emphasizes biological functioning, and problems in female sexuality are viewed primarily through a medical perspective as physiological problems. The model promotes a division between mind and body in which mental factors do not affect the body and vice versa . Sexuality, a complex phenomenon involving varied biopsychosocial factors, becomes distilled into its physical manifestations and thus oversimplified and confined to the individual. Social factors such as power dynamics, sexual rights, and diverse cultural meanings for sex are not considered as possible factors, and consequently don't become foci of research or treatment .

Medicalization of sexuality has some advantages. Women with sexual problems related to pain or physiological imbalances benefit from having a medical label under which to be recognized which grants legitimacy and often financial support. A physiological condition often carries less stigma than a psychological problem. Additionally, because sexuality is such a meaning-laden topic for people, discussing it from a biological framework can provide a neutral platform from which to start. This can be important for public health initiatives or getting sexual education curriculum approved.

However, embedded within medical assumptions regarding sexual health and dysfunction are values that prioritize orgasm, sexual availability, and a heterosexual script that focuses on vaginal penetrative sex . In the process of medicalization, behaviours, thoughts, and feelings associated with sex become divided into 'normal' and 'abnormal', and categorizing sex as 'healthy' means disinterest or varying levels of interest in sex becomes 'unhealthy' .

Specific to the medicalization of female sexuality (as male sexuality has also been medicalized) is the way in which the gendered and political nature of sexual power and sexual relations are disregarded. It does not acknowledge that female sexuality is value-laden and monitored, or the varying cultural expectations for women to marry, bear children, or have socially mandated sexual inexperience . It does not recognize that in many cases women trade sex for resources, socioeconomic status, or security. It ignores the ways in which self-esteem, mental health, relationship quality, work load, stress, and aging all have impacts on a woman's interest in sex in general, or her desire specifically for her partner.

Female sexuality is thought to be particularly vulnerable to the relabeling of healthy variation as dysfunctional, as aspects of female sexual response are not necessary to reproduction (e.g. arousal, orgasm) and are thus subject to social control and culturally guided sexual expectations. During a US Food and Drug Administration (FDA) patient-focused public meeting on female sexual problems in October of 2014, it was noted that most of the concerns voiced revolved around low sexual desire. Many of the women (predominantly white, heterosexual, and cis) expressed that their lack of desire made them feel guilty towards their long-term partners, saying they wanted to approach sex with their husbands out of joy rather than obligation because then "I feel like I am contributing". Very few women mentioned wanting medication in order to feel sexual pleasure, and when it was mentioned it was almost always in the context of partnered activity (as opposed to masturbation). This implies that for many of the women boosting their sexual interest was less about experiencing pleasure and orgasm for themselves and more about participating in social expectations of what a woman owes her (male) partner regarding sex and sexual enjoyment.

Recent History of Female Sexuality in Medicine

Sexual response cycles as described by Masters and Johnson. These cycles have been criticized for focusing primarily on physiological phenomena, and inaccurately representing female arousal changes.

The medical model of female sexuality is still largely based on the Masters & Johnson physiological model developed in 1966 . This model had a number of methodological problems, not least was the definition of a 'successful sexual encounter' as one that results in achievement of orgasm for both parties. This results in the categorization of any sexual encounter in which orgasm does not occur as 'unsuccessful', thus excluding a wide range of non-orgasmic sexual behaviours and encounters. The model also heavily emphasized a linear model of arousal and sex, which has been shown not to reflect women's experiences of sex .

Since the 60's, research has been primarily physiological. It is only in the last two decades that work is being done to address social, psychological, and cultural factors, with much of the research being done by sociologists, psychologists, and feminist scholars as opposed to the medical community. Voices from within the sex therapy community describe a general lack of interest in female sexuality research from the field of psychiatry, and even a lack of education at medical school, leaving a medical research space which has largely been filled by pharmaceutical companies.

For the past several decades, female sexual problems have operated under the umbrella term 'female sexual dysfunction' (FSD). Prior to 2013, specific diagnoses for female sexual dysfunctions in the 4th version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) had no requirements for contextual factors, problem duration, or frequency. In 1999 a study by Laumann, Paik, and Rosen was published with the claim that 43% of women in North America experienced sexual dysfunction, a number that was and occasionally still is used by the media, despite the fact that the authors of the study were forced to modify their claim due to significant methodological problems with the study. Accurate numbers are difficult to establish, but a meta-analysis has found a prevalence of 5-10% for female orgasmic disorder. The recent release of the DSM-V in 2013 saw considerable improvement to the diagnostic criteria of female sexual disorders, including the requirements for minimum duration, frequency, consideration of contextual factors, and an element of personal distress.

There is no current medical consensus on what causes female sexual dysfunctions, due in part to lack of medical research and the narrow view through which medicine has approached sexuality. Research performed in other fields suggests that when asked what bothers them about their sex life, women more frequently respond with non-medical issues such as relationship quality or work-life balance. To that end, treatments that emphasize couples counselling, life skills, or sexual education may be as valid, if not more valid an approach as a biomedical one. If research on mental health can be extrapolated to sexual problems, as some sex therapists contend, the most effective treatment for sexual problems may be a combination of psychological treatment and pharmaceutical assistance.

Post-Viagra Pharmaceutical Rush

When Viagra was approved in 1998, pharmaceutical attention turned towards female markets. Only a year later, the Laumann et al. article came out, declaring the 43% prevalence of female sexual dysfunction, generating the idea that almost half of North American women were experiencing a biological sex problem.

Initial efforts consisted of applying the male erectile medication (phosphodiesterase 5 inhibitors) to women, but it proved ineffective and had a number of side effects, including worsening sleep apnea. The following slew of pharmaceutical efforts reflects the medical community's poor understanding of the root causes of female sexual dysfunctions. Viagra, Alista and Femprox are vasodilators that increase blood flow to the genitals. Intrinsa is a testosterone supplement. Addyi addresses brain chemistry. To date, only Addyi has been approved by the FDA, but both vasodilators and testosterone supplements are prescribed to women off-label for the purposes of increasing sexual desire.

Feminist Narrative and Big Pharma

Addyi was approved in 2015 as a treatment for Hypoactive Sexual Desire Disorder, a diagnosis had been defunct since the introduction of the DSM-V in 2013. The

Even the Score's 'victory thank you' video, which frames the

introduction of women's sexual dysfuction medication in terms

of utilizing a man's "four hour erection".

approval came after a protracted media campaign by a group called Even the Score, which contended that the lack of FDA-approved medication for female sexual dysfunction was evidence of gender bias on the part of the FDA as opposed to a lack of safe and effective drugs. The media campaign created a dichotomy in which either the FDA approved a female sexual dysfunction drug, or the organization was sexist . The group appears to have been a co-opting of feminist agenda for profit, as they promoted misinformation about the gender imbalance of sex-related medication and the existence of effective medication for women. Tellingly, the owner of Addyi, Sprout Pharmaceuticals, has been unofficially identified as a founding organizer of the campaign. The campaign disappeared soon after Addyi was approved.

For a drug touted as the 'pink Viagra', Addyi is somewhat underwhelming. As a re-purposed anti-depressant, it must be taken daily, works for only 9-14% of the population and offers an additional 6 to 7 "satisfying sexual events" per year. Users must refrain from consuming alcohol and common medications including hormonal contraceptives and several antibiotics while taking the drug. Potential side effects include severe low blood pressure and unconsciousness. The drug is not covered by Medicare and employer insurers willing to cover it require women to make appointments with psychiatrists prior to approval.

Addyi has not been commercial successful. Since it's approval in 2015, Addyi has only been prescribed ~23,000 times. Approximately 82% of the prescriptions made in 2015 went unfilled, in contrast to the half a million prescriptions filled for Viagra in the first month of it's release. In July of 2018, Sprout Pharmaceuticals dropped Addyi's price from $800 to $400, provided a streamlined prescription and delivery service, and has promised those without insurance coverage won't have to pay more than $99 per month. It is yet unclear how this will affect prescription and adherence rates.

Anti-Medicalization Feminist Activism

In early 2000 sex therapists, feminist scholars, and psychologists organized to form a group called the New View. The group focused its attentions on challenging medicalized views of sexuality by promoting sexual research and education from a meaning-centered as opposed to a function-centered

The New View Campaign Capstone Video, released at the

conclusion of the campaign.

focus. They were instrumental in preventing the approval of a number of FSD drugs that did not meet efficacy or safety requirements when the FDA was facing pharmaceutical pressure, which may have led to the creation of Even the Score. In October of 2016, the New View decided to conclude it's campaign. They consider their campaign successful, having achieved their goals of creating a space for feminist critique of sexual medicalization processes and sparking the genesis of new paths of research and thought.