Quest for the female orgasm

The pharmaceutical goldrush triggered by Viagra has forced female sexual dysfunction out of the bedroom and into the market place

Maureen Rice

Viagra started it. When the drug went on sale in 1998, it changed the sexual landscape as significantly as the birth control pill. Suddenly men were talking about their impotence in public and in unprecedented numbers, in a wave that started in their doctor’s surgeries and crashed in a thousand headlines.

But Viagra was an insignificant blip on the radar compared to what’s coming next. The drug had an unexpected and explosive side-effect: women wanted it. Or, if not Viagra, something like it. For the first time, the scale of female sexual dissatisfaction was revealed, along with a wide-scale demand for effective treatments.

“Viagra opened up research into female sexual dysfunction [FSD] and that may yet turn out to be its greatest contribution,” says Dr Alan Riley, professor of sexual medicine at the University of Central Lancashire, and one of the United Kingdom’s leading authorities on the subject. “Until then, sex researchers had largely concentrated on improving performance and pleasure for men. The scale of the female problem was probably the biggest shock. It’s a new field, but everyone is racing to catch up.”

There’s a lot of catching up to do. At least 40% of women report serious problems and lack of satisfaction with their sex lives. That’s a number that stays consistent across a wide range of studies in the United States and Holland - world leaders in the field of sex research - and in the UK. Take 40% of women with sexual difficulties and what do you have? An epidemic? A movement? No, you have something far more powerful: a market.

Viagra made a fortune for Pfizer, the company that developed it - more than $1- billion in the US in the first year - turning Pfizer into the second-largest drug company in the world. It’s estimated that only one in 10 men suffers sexual dysfunction problems, compared to four in 10 women. It’s what corporations like to call “a no brainer”.

Sexual frustration is suddenly very sexy, and the world’s leading pharmaceutical companies are lined up in the race to develop wonder drugs to boost libidos, heighten arousal and, the biggest prize of all: control the female orgasm.

On the face of it, this could be a win- win scenario. Frustrated women suddenly find themselves legitimised and listened to, with Viagra’s billion-dollar jackpot acting as a finely tuned hearing aid. It ought to be a perfect modern marriage: consumer demand meets supplier know-how in an age of patient choice and - finally - true sexual equality. But being a modern marriage, it is fraught with controversy and conflicting agendas.

Will a new wave of sex drugs herald a great feminist breakthrough? Or reduce us all to a series of body parts and produce a generation of women all having the “correct”, clinically endorsed four orgasms weekly? Will drugs actually work? Does sex therapy actually work? And who is really most bothered about all those faked orgasms - women or men?

Dr Martin Cole is the recently retired head of the Sex Education Institute in Birmingham. He spent 20 years as a sex therapist, pioneering the controversial use of sex surrogates - temporary sexual partners - for treating sexual problems. He believes that the new wave of drug treatments for FSD is as significant in its own way as the development of antibiotics. “We’ve come to the limits of treating sexual problems with psychotherapy, and we’ve been largely barking up the wrong tree with the treatments we’ve used. Fair enough - they were all we had. But most sexual disorders have their roots in the physical. Look how Viagra has transformed our treatment of erectile dysfunction. I’m betting it’s cured more problems in the past two years than therapy has in decades.”

Like many of the researchers at the sharp end of developing the new drug therapies - largely in the US - Cole is impatient for their appearance as conventional treatments. “They are what will finally make the big difference. There are analogies here with a whole list of other problems that we used to treat as psychological and have since shown to be neurological. It wasn’t all that long ago that mothers with autistic children were accused of causing their child’s disorder by coldness or neglect. The big advances in treating illnesses like depression or schizophrenia have come from drugs, not from therapy.”

Cole’s enthusiasm for the possibilities of drug therapies is echoed almost unanimously by US researchers and therapists. They may be employed by huge corporations with bottom-line motivations, but that doesn’t mean they see their work in quite the same way. For some, there’s a frontier-spirit evangelism about their research, a spirit of the quest in the search to understand, redefine and liberate female sexuality.

FSD may be a new field of study, but it isn’t a new complaint. Sex researchers agree that the 40% of women currently suffering problems have probably always been with us - it’s just that nobody bothered to survey them before. “The numbers may even have decreased,” says Alan Riley, “given how restricted and repressed women’s sexual expressions were for so long.”

Now we not only have a name for the condition, but a series of names and sub- categories. Broadly, the new therapies aim to treat four main problem areas: desire disorder (reduced or nonexistent libido), arousal disorder (lack of lubrication, blood flow to genitals, inadequate sensation), orgasmic disorder (orgasm difficult or impossible to achieve) and painful intercourse (penetration causes pain, often to a degree that makes intercourse impossible).

Until Viagra, almost all therapy for these disorders was psychotherapy. You talked; your therapist listened. You may have been sent home with a series of exercises to try, either alone or with a partner. If you were a woman, you may have had your birth control pill changed to affect your hormone levels, or even been offered a diet and exercise programme. Recently, there has been some movement towards treatment with hormone therapy, and particularly with injections of testosterone, the “sex hormone”. That was it.

The new drug therapies, on the other hand, are concerned with the physiological symptoms and treatments of FSD. Although there are literally dozens of new treatments in research, they fall into one of two main categories: hormone treatments (usually oestrogen, testosterone, or a combination of both, administered by injection, pill, patch or topical cream to improve sexual response) or vasodilators (drugs, like Viagra, that dilate blood vessels and increase blood flow to the genitals, an important component of sexual arousal in both men and women). At least one company is working on developing a vasodilator in a vaginal suppository, a formulation believed to improve both lubrication and blood flow. The promise is that drugs will eventually be developed to treat all aspects of FSD, with multiple treatments for those who need them.

Because types and dosages of drugs will vary according to need, clinicians will need to accurately diagnose their patient’s problem. Currently, diagnosis can only be carried out on very motivated patients. It may not surprise you to learn that few of them are British.

Here’s a typical diagnostic scenario for patients with FSD: a woman who has complained of a lack of sexual response is wired up to a series of devices and probes. “Stimulus material”, such as pornography, may be used, or the woman may be asked to use a vibrator, or a combination of the two. A small light attached to a black box is inserted into her vagina, which then measures changes in vaginal blood flow and redness, a pH probe will measure alkalinity, and another probe will measure changes to the length and width of muscle tissue. Finally, a biothesiometer is used to determine sensitivity of the clitoris and labia to applied pressure. These readings are taken before and after stimulation occurs, and used as a basis for diagnosis. In current trials, the same readings are taken again after administration of a drug.

Not since Masters and Johnson has the precise anatomy and physiology of sex been so minutely studied. One clinic is reported to have taken full body scans of a couple having sex inside a version of an ultrasound machine. They were French, apparently.

In other words, the drug manufacturers are attacking FSD from all angles, but from a completely different direction to most sex therapists - as an organic disorder: measurable, diagnosable and chemically treatable. And in that difference of opinion lies a medical cat fight of epic proportions, with parallels in the current debates over drug versus therapy treatments for other disorders such as depression, schizophrenia and anorexia nervosa.

According to Dr Michael Crowe, a consultant psychiatrist and head of the Couple and Sexual Clinic at London’s Maudsley hospital, the pharmaceutical solution is just too simplistic. Like most sex therapists, he maintains that the apparent chestnut of a woman needing a cocktail of love, romance and security to enjoy sex is actually a profound truth. “To state the obvious, women are very different to men,” says Crowe. “There are many different kinds of FSD, and many reasons for it. Women’s sexuality is more complicated and multidimensional than men’s. The physical and emotional are connected in a way that makes them inseparable.”

“We have to be very careful of making generalisations,” warns Riley, “but in the majority of cases, that’s true. Equally, many men may prefer to have sex under the same conditions, but it isn’t so necessary. Female sexual response is intrinsically tied to a woman’s emotions, whereas men can have satisfying sexual experiences with no emotional investment at all.”

Forty years of the women’s movement and five years of “Girl Power” haven’t changed the fundamental fact: it’s different for girls. It’s for this reason that Riley - and most of his UK peers - believes that drug therapy can only ever have limited success in treating FSD.

Although Viagra is not licensed for use on women, it has been used on small numbers of female patients, with mixed results. “Viagra achieves its effect by increasing blood flow to the genitals,” says Crowe. “That creates erections in men, and is also an important symptom of arousal in women. While it increased blood flow in many of the patients, it only increased arousal in some. A man with an erection will automatically feel desire. A woman with the physiological characteristics of desire may still say that she doesn’t feel sexy. Viagra doesn’t resolve relationship problems, or improve sexual technique, or resolve other kinds of conflict. Viagra doesn’t work on the brain, and for most women that remains a key erogenous zone.”

It’s a fact that no drug has yet been invented that can restore love or desire in a woman who can’t stand her husband. And it’s also a fact that lack of desire is cited by therapists as being by far the most common cause of FSD. It’s also the most difficult to treat - especially with drugs.

“Loss of desire can have a lot of causes, often simultaneously,” says Riley. “It may be affected by anger and resentment within the relationship; by fatigue; by the menstrual cycle; by a woman’s multiple roles of mother, friend, worker; by hormonal deficiencies or imbalances; by depression or anxiety. It may be caused by previously traumatic sexual experiences, or just by a series of inept or unsatisfying sexual encounters. Drugs can’t resolve relationship issues or improve a woman’s partner’s love-making techniques.”

Another problem with drug therapy is that it is a goal-focused treatment, with orgasm as the goal. According to some sex therapists, this can create more problems than it solves. Dr Fran Reader is a gynaecologist and sex therapist with many years’ experience of treating FSD. “There’s no doubt that Viagra has really improved our treatment of erectile disorders, but it has put the focus of sex therapy back on to the erection and the orgasm. The danger of researchers now focusing on drug therapies is that we will be educated to believe that there is a ‘correct’ and desirable sexual norm, when there’s no such thing. Many women have very few orgasms, or even no orgasms at all, and they don’t really mind, so long as they feel they are having good sex. That’s good sex for them, and not according to a prescription. That may include much broader definitions of intimacy and sensuality than popular ideas about ‘good sex’ allow.”

The notion that women might not be having orgasms but aren’t really bothered about it sounds like heresy in our highly sexualised culture, but every therapist I spoke to endorsed it.

Says Crowe: “It’s true. And a number of the women who do mind, mind because they are surrounded by totally unrealistic and stylised images in magazines, films and advertising of multi-orgasmic women who are in a permanent state of desire, easily aroused, and on the ceiling within two minutes of getting into bed. It’s frankly ridiculous, but it’s wormed its way into our consciousness so that many women - and men - feel short-changed and frustrated that their own experience is nothing like that. A healthy and satisfying sex life is a completely legitimate goal, but our expectations have become unrealistically high.”

Like Reader, Riley is wary of anything that attempts to “normalise” sexual response, which is enormously various. “Some people are just naturally less libidinous than others, just as some people are less cheerful, or more optimistic.”

Forty per cent of women claim FSDsymptoms. How many does it take before those symptoms aren’t seen as dysfunctional but normal?

“That’s the trouble with definitions of ‘normal,’” says Riley, “especially as strictly defined ‘normal’ sex is precisely the kind nobody wants to have. Biologically, it’s only necessary for a woman to feel sexual desire once a month, when she’s ovulating. And premature ejaculation in men is biologically normal, as it allows him to impregnate the highest number of women in the shortest possible time. Sex for pleasure is a construct of civilisation, and the role of sex therapy of all kinds is actually to ‘cure’ the normal, and make the ‘abnormal’ normal.”

No treatment of FSD can work - or even begin - without understanding what the patient wants to achieve. “Sometimes a woman will present herself as having a problem, when the problem is actually the man’s,” says Reader. “Or she’ll say that she’s gone off sex, and it can take time and careful questioning to find out exactly what she means by that, or why it has occurred. It can be very difficult to separate what is actually a real loss of desire, and what is an expression of a relationship conflict.”

Crowe points out that while women may be upset and unhappy about their sex lives, it is rare for them to feel the devastating loss of identity that sexual problems can cause men. “It’s another of the fundamental differences,” he says. “I don’t downplay the misery that FSD can cause, and in some cases it can be intense. But impotent men may feel suicidal. Their relationships can break down, and their careers collapse, as feelings of failure pervade their whole life. Women sometimes experience the same kind of feelings with sterility, or even after a hysterectomy, but generally not to such a degree with sexual disorders, unless there is a history of abuse.”

But the male response can be projected on to his partner. It’s already quite common for sex therapists to see women who come for treatment “because my husband thinks I should enjoy sex more”. With the promise of a drug company’s magic bullet, rather than the more difficult and revealing work of therapy, that situation is likely to increase.

“Many men feel that a woman’s orgasm is their responsibility,” says Reader. “Because orgasm is so important to him, he believes it is the same for her, and feels a failure if she doesn’t climax. It can create a compulsive need to bring her to orgasm, which puts them both under pressure. A number of women seek sex therapy because their partners are more concerned about their sexual response than they are.”

And let’s not ignore all the implications of that concern. As the psychoanalyst John Munder Ross has pointed out: “The man has a narcissistic anxiety that he’ll be considered unmanly if the woman doesn’t come. But it’s also a new, sexually correct variation on a familiar theme: the control of women’s sexuality. The man may be in awe of a woman’s orgasm, but he wants to maintain the right to release or contain it.”

There’s a real concern that readily available drug therapies will end up as tools of that control, producing a nation of women like blow-up sex dolls, medicated into responsiveness without any need for all that tedious talking and consideration stuff. Most of the drug manufacturers are multinationals, but the greatest enthusiasts for drug treatments are in the US, a nation that loves its drugs.

The Ritalin experience should serve as a caveat: the US has a much higher proportion of children taking this drug than any other country. Originally prescribed for children with severe behavioural difficulties, it is now widely used to treat Attention Disorder Deficiency, a controversial condition that runs the gamut from extreme hyperactivity and aggression to what less-sophisticated nations call “kids being kids”. A child misbehaves; he’s prescribed Ritalin. A woman doesn’t have “enough” orgasms; she’s medicated. Oh, brave new world.

For the majority of sex therapists, at least in the UK and at least for now, drugs have a place in therapy, but as a supplement, not a replacement.

Riley and Crowe will welcome some of the new drugs as part of an integrated approach to therapy. “The best way to treat sexual dysfunction is to treat the relationship,” says Riley, echoing the view of most therapists. “For women in particular, and probably for more men than we realise, sexual disorders don’t occur in a vacuum. Ideally, I prefer to treat couples, if the patient is in a relationship, and to explore all aspects of the relationship, including the physical and psychological health of both partners.”

Crowe agrees. “I’m interested to see where the new drug therapies go, but they reduce a complicated, multidimensional issue to a series of mechanisms.”

“Well, they would say that, wouldn’t they?” says Cole. “British therapists all tend to peddle the same orthodoxy. It’s the therapy party line, and it’s just not working.”

A lot of the criticisms of focusing on drug-related therapy, he believes, amount to little more than a professional turf war. “There’s so much politically correct nonsense talked in therapy circles. A lot of its attention is given up to inventing and naming all these ‘disorders’. Many of them are so general or vague that they could apply to practically anybody, so we all end up as part of the victim culture with some kind of ‘disorder’, and that’s how therapy creates its own market.”

But for what he calls “real, medical sexual disorders”, the great breakthroughs will not necessarily come, he believes, with the “sex hormone” treatments currently being developed, but with the next wave of treatments based around the brain chemicals of seratonin, dopamine and adrenaline. “We already know that seratonin blockers, like Prozac, have the side-effect of inhibiting libido,” he says. “We can block desire with drugs when we want to, for example the ‘chemical castration’ used in prisons. Once we fully understand the role of the brain chemicals in arousal and response, I think we’ll have some amazing treatments.”

Yes, he admits, drug therapies do have their limitations. But therapy has more. “It’s true that women have a very different sexuality to men. Many problems of FSD are situational - they occur because the woman is angry or resentful or fed up in some way with her partner. Sometimes, people just do stop fancying each other. The best sex therapy under those circumstances might be to point out the apparently radical fact that sex is just one part of a relationship jigsaw, and it doesn’t have to be the most important part. Sometimes couples need permission to realise this - our culture puts us all under far too much pressure to have constantly mind-blowing sex. I’ve seen couples who get along famously in every other way but not in bed. Is it worth throwing away the friendship, love, mutual support and shared mortgage for the sake of a better orgasm? In many cases, it isn’t.”

At the moment, the debate about drugs versus therapy is an academic one. Most of the new therapies will not be available for at least another three years, and then there will be the issue of who can get them. When Viagra was licensed in the UK, it was initially unavailable on prescription, and then eventually available only to restricted groups of patients. Everybody else had to pay for it. It seems likely that the same terms will apply to the new treatments. They will be available for the sexually disabled, but thereafter only to the well-off dysfunctional, and the swingers who already form a significant black market for Viagra and who are looking for “enhancement” rather than “treatment”.

Good sex may improve the quality of our lives, but it’s not yet a civil right, or even a healthcare priority. To the frustration of the sexologists - and doubtless of their patients - improving our sex lives will largely remain in the realm of “lifestyle choice”.

The drug companies needn’t worry. Demographics and social trends are all on their side. Populations are ageing, and living longer, and the generation now approaching menopause and the whole raft of mid-life crises is the “Boomers”, the most famously self-obsessed and entitled generation in history.

Even so, Cole believes that the new drug treatments will work for, rather than against womankind in general, and not just the women who can afford them. “Women have had access to the best of medical attention in other areas of their life. The fact that drug manufacturers are now focusing on their sexual health tells me that we are finally moving towards real sexual egalitarianism, something we haven’t yet achieved. Women’s desires and demands are now not only allowed, but are finally being served.”

The US sex therapist Laura Berman, who runs a sex clinic at Boston University with her sister Jennifer, a urologist, agrees, though she adds: “We do have to be aware that drugs can be used to treat the symptoms but not the problems.” But she’s at the sharp end of treating that 40%, and sees the real misery and trauma that FSD can cause.

Like Cole, she believes that we shouldn’t let our techno-fears and lingering taboos about sex blind us to the life-enhancing qualities of the new treatments. “If there’s something that can be done to enhance a woman’s possibility for reaching her full sexual potential, I’m all for it,” she insists. “Addressing female sexual dysfunction is the final frontier of the women’s movement.”


l Good sex ends in orgasm

l Men need an erection to have sex

l The simultaneous orgasm is the goal of great sex

l Sex is “natural” and we all know how to do it

l Men are born with a blueprint that tells them what women want in bed

l Sex in the movies is realistic - in other words, women are easily aroused and men are as sexy as James Bond

l Sex means intercourse

l Men always want sex

l Sex should be spontaneous

l Men should take the lead in initiating sex

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