Female Sexual Dysfunction -- Medical Fiction?

Sept. 31, 2010— -- Many doctors have critiqued the over-medicalization of female sexual dysfunction by the pharmaceutical industry, but journalist Ray Moynihan, author of "Sex, Drugs, and Pharmaceuticals", goes so far as to argue that drug-makers helped to create the disorder.

"It has become clear that drug companies have not simply sponsored the science of this new condition; on occasions they have helped to construct it," he writes in an article published Thursday in the British Medical Journal.

Between industry-sponsored research that puts female sexual dysfunction (FSD) at epidemic proportions and industry-developed diagnostics that teach physicians how to make five-minute diagnoses, Moynihan argues that drug marketing has merged with medical science, influencing and even guiding medical perception of female sexual dysfunction.

"They did it for social anxiety disorder and for erectile dysfunction," says Dr. Marcia Angell, who teaches social medicine at Harvard Medical School. "They create a lot of buzz, and all of a sudden there's an under-treated epidemic -- and they have a ready-made market for what they turn out."

But would this supposed "creation" of disease by drug makers suggest that female sexual dysfunction, as a diagnosable medical disorder, doesn't really exist?

Some doctors would say so, arguing that the novelty of much of the medical discussion of FSD lends credence to the fact that it's predominantly an invention of the industry.

Sexual therapists and their patients, on the other hand, beg to differ.

The "argument that female sexual dysfunction is an illness constructed by pathologizing doctors under the influence of drug companies will fail to convince clinicians who see women with sexual dysfunction, or their patients," writes Dr. Sandy Goldbeck-Wood, a U.K. associate specialist in psychosexual medicine in an accompanying response to Moynihan's article.

Though the pharmaceutical industry's over-involvement in much of the research on the subject should certainly be called into question, she adds, the reality of these disorders and the distress they cause, should not.

Sexual Dysfunction: Myth or Medicine?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) IV classifies six different sexual disorders that plague women, including those affecting arousal, orgasm and pelvic pain, all of which fall under the banner of female sexual dysfunction.

Insofar as FSD is included in the DSM IV, "it is as real as any other DSM psychiatric diagnosis," says Sheryl Kingsberg, chief of the division of behavioral medicine at University Hospitals Case Medical Center in Cleveland.

But, the industry hype surrounding FSD has led some to criticize the extent or even the existence of these disorders, warning that doctors may be pathologizing normal ups and downs of libido in response to the industry's illusion of epidemic.

"There are probably women who don't fully function sexually, but that's very different from saying it's a diagnosable medical condition," Angell says. "That's a giant leap ... that presupposes we have more knowledge than we do."

Kingsberg counters that "any diagnosis is developed because there's enough evidence to show there is a syndrome," adding that in 20 years of personal experience, she has seen hundreds of women who would classify for the DSM's diagnosis.

"By not legitimizing it with a label, that's doing these women a disservice," she adds.

"Pharma can't invent something that has no resonance with people. They have to be responding to a need," says Pepper Schwartz, a sex expert and professor of sociology at the University of Washington.

"It's obvious that it exists," she adds, but that doesn't mean there's risk of women interpreting what is a normal cycle of sexual health, such as lulls in libido following pregnancy, as a pathological disorder.

And that doesn't mean that it afflicts women at epidemic proportions, with one in three or one in four women a victim of it, as some industry-funded surveys say.

Treating the Patient, Not the Diagnosis

There's an "improperly intimate research relationship between industry and clinicians," Goldbeck-Wood writes in her commentary, that casts doubt on some of the existing evidence on the subject.

But faced with patients who are suffering, sex experts point out, the prevalence can be beside the point.

"From my point of view and that of many doctors working in health, we don't know the exact number, but we know from our clinical practice that these are real patients consulting real doctors in real distress," Goldbeck-Wood says.

A Middle Ground: Integrating Techniques

The myriad issues in female sexual health are too complicated to be reduced to a quickie diagnosis or a magic pill, sex experts warn. Putting prescription power in the hands of a physician who has only a few minutes to diagnose is a dangerous prospect, warns Aline Zoldbrod, a Boston-based sex therapist.

"It takes sex therapists hours to tease out information from a woman and determine what's going on. You need to look at her marriage, how much stress she has in her life, whether she's depressed, whether she's ever enjoyed sex. It's not like doing a blood test," she says.

It's an unfortunate reality that if the pharmaceutical industry advertises a pill that's going to offer a simple solution to women's complex sexual problems, a lot of women are going to go for it, she adds, but that doesn't mean that that will be effective or appropriate treatment.

While the long hoped-for "female Viagra" might one day offer a pharmacological solution for many women's sexual woes, experts admit, the bottom line is that treatment of FSD needs to be nuanced and tailored to the woman's needs, whether that's through counseling, lifestyle changes, or medication.

"We should be asking ourselves: How can we help in an evidence-based way instead of just reaching for the prescription pad?" Goldbeck-Wood says.