Pills in the Bedroom

Sex, Lies and Pharmaceuticals: How Drug Companies Plan to Profit from Female Sexual Dysfunction is proof that investigative journalism still exists.

In recent decades, the medical establishment has dramatically expanded the definition of disease and dysfunction to include everything from sexual disinterest to obesity, from shyness to “hyperactivity” in children, with laziness now being discussed as “a neuro-developmental dysfunction.” Studies of new medical dysfunctions are repeated rather than reported upon by a mainstream media who does not seem to read beyond press releases in order to announce sensational findings.

Enter Ray Moynihan, a health journalist for the New England Journal of Medicine and the Lancet. In Sex, Lies and Pharmaceuticals, he and co-author Barbara Mintzes—an assistant professor in the Department of Pharmacology and Therapeutics at the University of British Columbia—scan a medical landscape in which “one in eight of us supposedly has social anxiety disorder, one in five is said to have irritable bowel syndrome, and in any given year we’re told a third of us have a mental illness.” Such statistics create an urge to wander with a lamp in daylight, like Diogenes, looking for a normal, healthy human being.

Moynihan’s response: a book that declares itself to be “an expose of how medical science is imperceptibly merging with pharmaceutical marketing” in order to create diseases or dysfunctions that have been traditionally viewed as bad habits, lifestyle choices or run-of-the-mill problems that everyone encounters from time to time. Moynihan and Mintzes ask a question that never grows old: cui bono?—who benefits? The answer may seem obvious. In tandem with new diseases and dysfunctions, a $500 billion–plus pharmaceutical industry has arisen and profited richly from “cures” like Viagra and Ritalin. The means by which Moynihan arrives at an obvious answer, however, are subtle and engaging.

Sex, Lies and Pharmaceuticals is a rarity—a book that lives up to its own hype. It is a thorough and meticulous exposé that does a remarkably good job of bringing skepticism without cynicism, information without sensationalism to an issue that is being confronted by an increasing number of average people. Do I take drugs to handle what might otherwise be considered an environmental or lifestyle problem, like packing on the pounds after menopause? Should I give drugs to my children so that they are not unruly in class? Is it fair to demand my husband swallow pills to enhance our sex life?

The questions become more pressing as the recall of drugs and the lawsuits over serious side effects become more common. For example, the popular diet drug Meridia was recently discontinued in Europe and may soon face the same fate in North America due to the newly reported risk of heart attack and stroke in people with existing heart problems. Against this backdrop, Moynihan and Mintzes offer a much needed voice of caution.

The book’s main title requires explanation. First, the word “sex.” There is nothing salacious or graphically sexual here. Arguably, the book is best viewed as a follow-up to Moynihan’s earlier co-authored work entitled Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All into Patients. That book deals with a whole range of relatively new medical “conditions,” such as social anxiety disorder (shyness) and menopause. Then, chapter by chapter, it explores the process by which pharmaceutical cures are marketed for a huge profit to people, many of whom would have been considered healthy a few decades ago.

Sex, Lies and Pharmaceuticals uses much the same approach but narrows its focus to the creation of a single modern medical dysfunction, a “disease” that is currently being defined and prepared for marketing: female sexual dysfunction. Moynihan describes the diagnostic specific for FSD:

From the initial stage of definition by medical experts through to the celebrity endorsements seen on TV, Moynihan carefully examines the tiered process through which a dysfunction is created and marketed. Because FSD so closely resembles its male counterpart erectile dysfunction, ED is used to draw parallels. Moynihan writes that “if you want to peer into the future of how the condition called female sexual dysfunction might play out, it will help to take a look at what’s happened with erectile dysfunction and the new sex drugs for men.” In 1992, the new medical term “erectile dysfunction” came into sudden prominence. “Unlike the ugly word ‘impotence’ that it replaced, erectile dysfunction was more clinical, more physical, making no judgement about the man’s potency. But it also implied the problem was that a man’s penis wasn’t functioning properly.” On the basis of studies Moynihan considers misleading or misinterpreted, large numbers of men were found to suffer from ED and to require medication such as Viagra.

Next, the word “lies.” The book does not accuse anyone or any faction of lying. At times, the events and actions presented lead almost inevitably to that conclusion, but Moynihan and Mintzes are carefully generous. For one thing, they clearly state their belief that many of the dysfunctions require or, at least, could benefit from medical treatment, including drugs. For another, regarding the development of FSD, Moynihan writes that “for many researchers, all this activity was bringing what they regarded as long-overdue recognition to women’s sexual suffering, and legitimacy to its study.”

The book presents a far more subtle point than lying for profit. Moynihan explores the extremely close, complex relationship between medical experts and the pharmaceutical companies, such as Pfizer and Proctor & Gamble, which wine and dine the experts, offer grants, provide lucrative speaking engagements, etc. For example, he explores the makeup of the expert committees that define dysfunctions and disorders for the extremely influential Diagnostic and Statistical Manual of Mental Disorders (DSM). The term “social anxiety disorder” comes from the DSM, which, interestingly, only delisted homosexuality as a disorder in 1970. Moynihan observes that

It is human nature to be open and positive toward ideas or projects that are to your benefit. This is especially true when the vast majority of information you receive comes from one source—in this case, the pharmaceutical industry or its affiliates—with critical voices being absent or underrepresented. Thus, Sex, Lies and Pharmaceuticals constructs a solid case for bias within the medical establishment but distinguishes it from lying.

Moynihan’s nearest approach to the accusation of lying is addressed to pharmaceutical companies and to “the fictions that flow from pharmaceutical marketing—like the notion that one in ten women suffers from a [medical] disorder of low desire.” Moynihan considers statements such as this to be medical disinformation.

Then there is the final element of the title: pharmaceuticals. Since it comes directly after the word “lies,” it is important to restate that Moynihan does not take an anti-drug stand in the manner of psychiatrist Thomas Szasz who, in several books including The Myth of Mental Illness: Foundations of a Theory of Personal Conduct and The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement, disputes the moral and scientific foundations of psychiatry itself and presents modern medicine as a form of social control. Rather, this book argues that dysfunctions have been massively over-diagnosed and drugs have been over-prescribed—a situation that, in and of itself, is a danger to public health.

So how is FSD being created? Moynihan and Mintzes lay the process out clearly. First, a phenomenon is noted; in this case, it is the difficulty that some women—especially post-menopausal ones—experience in feeling sexual excitement.

Then a medical definition is formulated by researchers and other experts who gather at conferences that are often funded by pharmaceutical companies. Moynihan writes that “when one distinguished group of researchers sat down to refine the definitions of FSD, 95 percent of them had financial relationships with the drug companies hoping to develop drugs for the very same condition.”

After formulating a definition, studies and surveys are conducted to establish the prevalence and other particulars of the new dysfunction. Moynihan examines in some detail a landmark survey on FSD, again funded by a pharmaceutical company, which was reported in a 1999 article in “one of the world’s leading medical journals … the Journal of the American Medical Association.” He refers to the article’s major finding as “one of the most pervasive medical myths of our time … The evidence assembled in the article never supported such an assertion, as even its lead author attests.” The myth: “43 per cent of women suffered from some form of sexual dysfunction.” Moynihan explains that the 43 percent figure is based on an hour-and-a-half-long interview that was designed to study HIV/AIDS. Within the interview, however, there were a few questions addressed to women about whether they had experienced any of seven common sexual difficulties during the past year such as performance anxiety or a failure to orgasm. Of the women interviewed, 43 percent gave a “yes” answer to at least one of the seven questions, and so 43 percent were deemed to have FSD. Notably, none of the women were asked whether they viewed the difficulty as a problem or what they thought the cause might be. For example, a woman might be suffering from an illness, have chronic back pain or be in a bad relationship. Nevertheless, the 43 percent figure has been cited in scientific papers more than 1,000 times and has filtered down to the pulp magazines sold in supermarkets.

In 2007, a British study that was not funded by the pharmaceutical industry had doctors ask similar questions of female patients. It found 38 percent of the responding women potentially qualifying for the dysfunction. The figure fell to 18 percent when the women were asked if they viewed the difficulties as problems; it fell to 6 percent when asked if the difficulties bothered them.

After the definition and studies that establish “unmet needs,” there is the “development of toolkits” with which researchers and doctors can measure the effectiveness of various treatments. Moynihan sketches the various tools being implemented, including “vaginal pulse amplitude” or VPA, which measures blood flow to the vagina of women who are watching erotica. Here, as with the question of “lying,” once more, Moynihan is careful. While pointing out the severe deficiencies of current tools, he also states that “there’s no implication here that research into the physical side of sexuality is unnecessary, or that shining a light on the walls of a woman’s vagina is a joke.”

The final stage of disease creation is to educate the public through a public relations campaign. Here, again, the marketing path of erectile dysfunction serves as the guide. When Viagra appeared in the early 1990s, it was marketed to older couples as a medical treatment for chronic problems and endorsed sedately by the former American presidential candidate Bob Dole. Within a few years, however, the target audience shifted to younger men who might be experiencing occasional difficulty. And then it shifted again.

Moynihan captures the last marketing expansion by referring to a “high-profile television commercial” for Viagra in which a man is window shopping and admiring sexy lingerie. The voiceover asks, “Remember that guy who used to be called ‘The Wild Thing?’ The guy who wanted to spend the entire honeymoon indoors?” A trumpet blows in the background and the voiceover declares, “He’s back.” The drug is now marketed as a lifestyle choice with no indication that the man in the commercial has what would normally be considered a “sexual difficulty.”

Dozens of variations on the “Wild Thing” commercial air constantly in the United States, often featuring women who are palpably thrilled to have their husbands on “the pill.” If Moynihan is right, we can expect to start seeing a barrage of ads targeting women in the future.

There are some flaws in the approach that Moynihan and Mintzes have taken. Sex, Lies and Pharmaceuticals presents the medical theories, studies and other arguably dry material it critiques in an accessible and generally engaging manner. For those who wish to verify points or to pursue them further, it also provides some 20 pages of notes and citations. Unfortunately, it is much better at exposé than it is at grounding its own position. For example, as a foil to the findings he is criticizing, Moynihan repeatedly cites the work of sex research Alfred Kinsey, whose research has been called into such question that his name weakens Moynihan’s position.

In presenting what is clearly his own perspective, Moynihan uses the voice of Lenore Tiefer, a psychologist at the New York University School of Medicine, who has created the New View Campaign in active opposition to the medicalization of women’s sexuality. Tiefer believes sexual difficulties are best “cured” through addressing all their causes: negative social conditions, a mismatch or absence of partners, psychological states such as depression and, when they exist, medical problems. Tiefer’s views on FSD are provocative and well argued but, at times, Sex, Lies and Pharmaceuticals almost seems like a platform built for Tiefer whose New View Campaign also advocates a wide range of international sexual rights, such as “the right” to medical care for sexual problems. Notably, the first street protest held by the campaign was “to protest the growth of female genital cosmetic surgery.” Moynihan would have been wise to include a broader range of voices against FSD.

Finally, the book falls into the trap of overwhelming the reader with details of conferences and studies. It repeats the same points so often that some chapters become tedious. It is an understandable flaw. Moynihan and Mintzes have done an admirably thorough job of research and I can almost hear them protesting “but we had to cut out so much!” They should have cut more.

Overall, though, Sex, Lies and Pharmaceuticals is an eye-opening, carefully written and fair book that directly confronts a single dramatic example of what many consider to be an exploding problem: the medicalization of everyday life.