The marketing of a disease: female sexual dysfunction
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7484.192 (Published 20 January 2005) Cite this as: BMJ 2005;330:192
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I thank Petra Boynton for her comments. I agree that there are
difficulties in defining sexual dysfunction, and there is a great danger
in medicalising a condition for which many women seek no help, and which
they perceive as being 'normal for them'.
However, there is a cohort of individuals who do feel the need to
seek medical help, such as resulting from another medical problem that
leads to sexual difficulties. In this population, when testosterone levels
are found to be low, then a trial of testosterone may be warranted. It is
certainly not everyone who has a low testosterone, nor for everyone who
complains of sexual dysfunction. Thus, as with every drug prescribed, it
should be the discretion of the prescribing physician to decided if the
change in sexual function that the patient describes, along with the
condition that may have caused the change in androgen levels and thus the
change in sexual function.
Competing interests:
None declared
Competing interests: No competing interests
Ketan may wish to re-read some of the papers cited in his letter.
Many researchers assessing sexual functioning are concerned about the
way in which female sexual dysfunction is being constructed.
Measuring dysfunction doesn't mean that researchers don't have
concerns about how female sexual dysfunction is being overmedicalised, at
the expense of social and cultural factors affecting men and women.
Estimates that women's sexual dysfunction levels are in the region of
40% have also been criticised, given women may report what a
questionnaire study defines as a 'dysfunction', but they don't report
being unhappy with their relationships.
In our paper (Nazareth, Boynton and King) which Ketan sites, we said:
"Much less is known about sexual difficulties in women, and criticism has
recently been expressed about the involvement of the pharmaceutical
industry in "building the science of female sexual dysfunction."20
Although the results of a British population study of women accord with
our findings,21 a woman centred definition of sexual problems has recently
been preferred to concepts of sickness and health.19 20 The word
dysfunction implies a state of "disease" that needs rectification. Our
data indicate, however, that sexual dysfunction cannot be considered as
one generic problem. Dyspareunia, vaginismus, reduced arousal, and
aversion to sexual contact were uncommon problems and were associated with
other psychological and physical difficulties. Women with these ICD-10
diagnoses were also much more likely to have consulted their general
practitioners about sexual matters than women who received a single
diagnosis of lack or loss of sexual desire. This suggests that many people
do not regard lack or loss of sexual desire as a serious difficulty".
Overmedicalising women's sexual functioning, ignoring other factors,
and specifically quoting high levels of female sexual dysfunction out of
context, is not helping women, or their partners.
Competing interests:
I have completed research on sexual functioning.
Competing interests: No competing interests
Ray Moynihan's article on the marketing of a disease, namely female
sexual dysfunction, is a trenchant comment on some unlovely aspects of the
pharmaceutical industry. The scientific basis for the existence of the
disease is controversial, as is the desirability of "treating" the
"disease" with a testosterone patch. This view was endorsed by the
advisers to the Food and Drug Administration when they recommended that
the patch should not be approved for marketing.
Mr. Moynihan feels that women are at risk of being exploited, because
they are being encouraged to take a medicine that may be unnecessary and
worse, may be harmful.
There is nothing new about this. For centuries, women have been
exploited for commercial gain, and with great success. Billions of pounds
are spent by women each year on cosmetics, perfumes and fashionable
clothes. They purchase uncomfortable shoes that imperil the health of
their feet. Vast amounts are spent on hair and skin products, encouraged
by dubious claims of restoring youthful properties. Dental entrepreneurs
offer effective but very expensive measures to beautify the teeth. In the
search for perpetual youth, collagen is injected into lips and botulinus
toxin into facial muscles. Tattooing and body piercing are expensive,
insanitary and deforming assaults on the human frame. The beauty industry
promotes the desirability - or the necessity - of possessing a perfect
figure: hence innumerable questionable diets and ever more ingenious
plastic surgery are promoted and huge profits are made.
If diets, cosmetics, hair shampoos and nonmedical dermatological
products were subjected to strict regulation, and scientifically
acceptable proof of efficacy was demanded, many such products would
disappear from the market and the exploitation of women would be
drastically reduced.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
In the article by Moynihan on whether female sexual dysfunction is a
product of a pharmaceutical executives’ fevered imagination or not, he
makes the statement that there have been no published peer reviewed
articles on testosterone replacement in women. This incorrect, Jan
Shifren, who is quoted later in the article, herself had a Proctor and
Gamble sponsored trial published in the New England Journal of Medicine
(1).
Several independent authors have reported the prevalence of some form
of sexual dysfunction in women between 18 and 75 years of age in the
region of 40 to 45% (2-5). It is difficult to imagine that these authors
have all been ‘bought’ by Big Pharma. These studies show, amongst other
things, that those who suffer most, are those who have lower androgen
levels than those in whom sexual function is reported as ‘normal’
There is, however, broad agreement that there has previously been
inherent difficulty in establishing the ‘normal’ range for free and
bioavailable testosterone in women, because it is only recently that the
ultrasensitive assays have become available. Many of the assays used
previously have not been able to detect any circulating testosterone in
women. Thus, much of the initial data used to create the ‘normal range’
may not have taken this into account, and so it is highly likely that many
of the women used to establish ‘normal’ values had some form of sexual
dysfunction, with a large proportion having low testosterone levels. This,
however, would underestimate the true prevalence of this condition.
1. Shifren JL, Braunstein GD, Simon JA, Casson PR, Buster JE,
Redmond GP et al. Transdermal testosterone treatment in women with
impaired sexual function after oophorectomy. N.Eng.J.Med. 2000;343:682-8.
2. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United
States prevalence and predictors. JAMA 1999;281:537-44.
3. Nazareth I, Boynton P, King M. Problems with sexual function in
people attending London general practitioners: cross sectional study. BMJ
2003;327:423-8.
4. Guay AT,.Jacobson J. Decreased free testosterone and
dehydroepiandrosterone-sulfate (DHEA-S) levels in women with decreased
libido. J.Sex Marital Ther. 2002;28:129-42.
5. Mercer CH, Fenton KA, Johnson AM, Wellings K, Macdowall W,
McManus S et al. Sexual function problems and help seeking behaviour in
Britain: national probability sample survey. BMJ 2003;327:426-7.
Competing interests:
My NIH/Mayo Foundation funded research assessed the effects of the adrenal androgen precursor dehydroepiandrosterone on sexual function in hypoadrenal women and healthy elderly women.
Competing interests: No competing interests
The rejection of Proctor and Gamble's experimental testosterone patch
by advisers to the US Food and Drug Administration in December 2004 was a
welcome relief in my 45 year battle against the misuse of hormones, either
for contraception or disease “treatments”.1,2 Ray Moynihan points out that
testosterone use is being actively promoted in spite to the proven
unacceptable increased risks with HRT.
The masculinising effects of contraceptive Pill androgenic
progestogens, which included migraine, hirsuitism, weight gain, acne,
hypertension and even violent aggression, were easily observable in the
1960s. An irony is that the main cause of sexual dysfunction in young
women is low dose oestrogen progesterone-dominant oral contraceptives
which dry up secretions, increase monoamine oxidase activities and cause
loss of libido and depression.3
Apart from obvious financial gain, some of the impetus to prescribe
testosterone or progesterone as HRT, in health and several diseases, is
due to misinterpretations of research results. Significantly lower levels
of testosterone and progesterone were recently found in the follicular
phase of normal ovulatory cycles in women with multiple sclerosis.3 Women
with post-Pill amenorrhoea and anovulatory cycles usually have severe
mineral deficiencies and ovulation can be restored with patience and
verified nutritional supplementation, in my experience. This suggests that
nutritional deficiencies may impede testosterone production first before
ovulation and luteal progesterone production become impeded later.
Okun and colleagues have also found lower serum testosterone levels
in patients with Alzheimer and Parkinson diseases.4 A knee-jerk reaction
is to prescribe testosterone in the same way as HRT has been given to
“treat” menopausal physiological falls in oestrogen and progesterone
production. This approach fails to consider the real reasons for
impairments in hormone production which are essential nutrient
deficiencies. Underlying severe deficiencies of zinc, magnesium and often
of copper are being found in recent studies of patients suffering from
numerous conditions including multiple sclerosis, Alzheimer and Parkinson
diseases.5,6 These common deficiencies also tend to intensify with ageing
but can be easily and safely corrected if supplementation is monitored by
mineral analyses.
The reality is that adding extra exogenous sex hormones to patients
who already have severe essential nutritional deficiencies will further
compromise failing systems and exacerbate the underlying mineral
deficiencies and imbalances. The WHI and MWS studies of the effects of HRT
were prematurely terminated because of unacceptable increases in vascular
diseases and cancers which are the inevitable consequence of fundamental
impairments of cellular function.
Why is the international medical community taking so long to come to
terms with these basic facts of life?
Apart from the obvious financial implications, hormone analyses are
more readily available than are white blood cell zinc, red blood cell
magnesium and red blood cell superoxidase dismutase activity analyses.
This situation should be remedied as quickly as is possible.
1 Moynihan R. The marketing of a disease: female sexual dysfunction.
BMJ 2005;330: 192-194 (22 January), doi:10.1136/bmj.330.7484.192
2 Grant ECG. Testosterone HRT is dangerous.
http://bmj.com/cgi/eletters/329/7477/1255#88135, 6 Dec 2004
3 Tomassini V, Onesti E, Mainero C, Giugni E, Paolillo A, Salvetti M,
Nicoletti F, Pozzilli C. Sex hormones modulate brain damage in multiple
sclerosis: MRI evidence. J Neurol Neurosurg Psychiatry 2005; 76:272-5.
4 Okun MS, DeLong MR, Hanfelt J, Gearing M, Levey A. Plasma
testosterone levels in Alzheimer and Parkinson diseases. Neurology. 2004
Feb 10; 62 :411-3.
5 Grant ECG. Damp climates, oestrogens, nutritional deficiencies and
multiple sclerosis.
http://bmj.com/cgi/eletters/330/7483/120#88738, 12 Dec 2004.
6. Grant ECG. Parkinson's disease and HRT.
http://bmj.com/cgi/eletters/329/7458/180#67686, 18 Jul 2004
Competing interests:
None declared
Competing interests: No competing interests
I cannot help thinking that if you need a multilayered global
marketing campaign, several public relations companies and major
advertising firms, and a budget of $100m, according to the data presented
by Moynihan [1], to create awareness of an ‘illness’ affecting a major
segment of the world population, then all those sufferers must be either
comatose or completely daft not to realize their dire predicament.
Alternatively, the implications of the disease in question are grossly
overemphasized.
Surely the promotion of female sexual dysfunction as a disease that
must be treated (at a huge profit) cannot be dissociated from the image
making business, be it cinema, fashion modeling, or plain commercial
advertising. The Western world is deluged daily by pictures, still and
moving, of men and women who look, dress, act and behave in a certain way,
and can perform physical or sexual feats over and above the average
mortal, who suffers from diurnal and seasonal variations in his or her
prowess or simply from human frailty and unhappiness. This brainwashing
has the effect that anybody whose performance is below par is compelled to
feel unwell and in need of a ‘booster’. Anabolic steroids represent such
boosters for athletes, and are rightly banned from legitimate use. Should
we not view sex steroids in a similar light?
1. Moynihan R. The marketing of a disease: female sexual dysfunction.
BMJ 2005;330:192-194.
Competing interests:
None declared
Competing interests: No competing interests
I encourage all women to reject the myths and artifically created
problems around our natural cycles of life in order to sell drugs. Our
life cycles are not a disease. I have never used HRT.
In reference to your article, I am not saying that female sexual
dysfunction does not exist, but to create an advertising campaign to
create huge problem for which a new drug will supposedly solve the problem
to me is unethical when there are natural solutions to support women
through our life cycle.
In my opinion, the difficulties surrounding perimenopause, menopause,
and post menopause are caused by our lifestyle--stress, toxins, processed
and fake foods, pseudoestrogens which block our hormone receptor sites and
drugs.
I encourage women to look carefully at what you are putting into and
on your body, and demand alternative natural solutions to your
problems.They do exist. You just need to want to find them.
Competing interests:
None declared
Competing interests: No competing interests
COITAL ALIGNMENT - The Bleeping Cure for FSD?
The discovery of the coital alignment technique (CAT), termed "the
new intercourse" in the media [1], may reflect an evolutionary step - a
change in sexual relating that fosters simultaneous orgasm. The CAT and
related breakthroughs in sex research are providing an understanding of
the nature of the sex act that is relevant to ethical issues posed in the
BMJ article "The marketing of a disease: female sexual dysfunction" [2].
Most importantly, the three classic problems of sexual "dysfunction" have
been redefined as interdependent parts of ONE behavioral syndrome - the
problems are NOT "diseases"; secondly, men and women play a mutual role in
each other's sex problems. The "cure" is a fundamental change in sexual
technique that is challenging emotionally because it transcends archetypal
gender tendencies; there is greater empathy.
PREMATURE EJACULATION (PE) - the man climaxes too quickly
Relevant to the timing of sexual response, every man knows that the
quicker he moves his hand in masturbation the quicker he reaches orgasm.
That scenario logically parallels his experience with intercourse. During
typical intercourse in the "missionary" position, a man is dependent on
friction from the speed of his "in and out" thrusting to keep his
erection. With heightened sensation at the approach of orgasm, he
automatically starts moving faster and harder -- that archetypal tendency
greatly accelerates his climax. Hence, "premature ejaculation" is a
direct result of the man's hyperactivity during coitus -- there is no
mysterious disease at work.
The male problem baffled the late Alfred C. Kinsey as evident in his
1948 report on Male Sexual Behavior [3]: "It would be difficult to find
another situation in which an individual who was quick and intense in his
responses was labeled anything but superior, and that in most instances is
exactly what the rapidly ejaculating male probably is, however
inconvenient and unfortunate his qualities may be from the standpoint of
his wife in the relationship" (p. 580).
FEMALE COITAL ANORGASMIA - failure of woman to climax from coitus.
In his 1953 Female report (1953) [4], Kinsey did a turnabout. He
stated, "There is a widespread opinion that the female is slower than the
male in her sexual responses, but the masturbatory data do not support
that opinion. Kinsey concluded, "It is true that the average female
responds more slowly than the average male in coitus, but this seems to be
due to the ineffectiveness of the usual coital techniques" (p. 164).
In typical intercourse, the faster and harder thrusting of the man at
the approach of orgasm CUTS OFF the orgasmic buildup of the woman -- It
would be physically painful for her to move as the man's movements becomes
more aggressive. The woman tends to adjust to the man as best she can,
often slowing or stopping any movement of her own. Hence, partners have a
mutual role in a scenario that makes it a PHYSICAL impossibility for the
woman to reach orgasm in coitus. (It'simple, one minus one doesn't equal
two.) The woman's failure to climax is rarely, if ever, caused by a
physical "disease" or a mental disorder (like so-called "frigidity").
HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) - lack of sexual desire and
arousal
It is logical that a long-term pattern of intercourse that does not
lead to complete and mutual sexual satisfaction for a man and woman would
eventually result in a loss of sexual desire. Recent media attention to
the problem of "sexless marriages" may reflect the fact that failed
intercourse can condition the woman (and also the man) creating apathy
about sexual relating. That conditioning process can also cause
"impotence" in the man, and "arousal" problems for the woman.
THE COITAL ALIGNMENT TECHNIQUE
The original CAT study [5] reported significantly high frequency of
female orgasm, as well as regularity of simultaneous orgasm. Controlled
replication studies reported effective treatment of Hypoactive Sexual
Desire [6]. The CAT research supports the premise of a natural anatomic
design for coital orgasm that is dependent on a specific interplay of the
male and female genitalia -- IN MOTION. That kind of model was called for
by pioneer sexologist R.L. Dickinson, the author of Human Sex Anatomy
(1949) [7]. The CAT technique involves a basic position and a coordinated
form of sexual movement:
(A) The basic position was referred to by Dickinson as the "riding
high" position in which the man is up forward along the woman with his
pelvis high up on hers; the base of his penis is bowed over the woman's
public bone pressing against her upper vulva stimulating her clitoris (and
urethral meatus).
(B) Secondly, a specifically coordinated pattern of sexual movement
must be maintained continuously. The woman leads the upward stroke with
the man providing a slight counter-pressure. The man leads the downward
stroke with the woman providing a slight counter-pressure. In the CAT
training, couples were instructed to think of orgasm as the build-up of a
"bio-electric" charge (as theorized by Freud [8] and his disciple Wilhelm
Reich [9]); they were told to let the orgasm charge overtake them without
disrupting the pace and pattern of their movement. Pioneer sex therapists
Masters & Johnson [10] experimented with the "male pelvic-override"
position; predictably, it failed because the subjects did not coordinate
their sexual movement sensitively (p 60). The man's heavy thrusting at
orgasm caused the woman pain. That kind of pain from the man's,
uncoordinated thrusting has been termed "dyspareunia," yet another
mysterious "disease".
THE PROSTATE (MALE AND FEMALE) - a primary erogenous zone
A video [11] was previewed at the 15th Congress of the World
Association for Sexology (Paris, 2001) that documented the CAT model in
real-time and synthesized researches relavent to the CAT model: The
sensory arm of the female prostate has been identified by the histologic
research of Milan Zaviacic [12, 13] as being at the urethral meatus,
correcting the "G-spot" researchers' assumption that it was located behind
the woman's pubic bone where it could not be stimulated directly by the
male penis during intercourse. Zaviacic's finding affirmed that CAT
provides simultaneous stimulation of both primary female erogenous zones -
(a) the clitoris and (b) the female prostate, polar zones for a complete
"blended" orgasm. Richard J. Ablin, whose discovery of the PSA is the
basis for the standard prostate cancer test, has revealed that male
spermatozoa deposited in orifices other than the vagina can be
carcinogenic (as in anal intercourse) [14]. Studies by clinical
psychologist Stuart Brody [15] have substantiated the premise that
intercourse is unique and effects many aspects of physical and mental
health; Brody has stressed that masturbation exercises do not help couples
to succeed with intercourse. In conclusion, there is a form to the sex
act that has a unique chemistry; as Freud concluded -- it is "imperative"
that the sex act be a regular and complete experience.
WHOSE AFRAID OF THE BIG BAD CAT?
The CAT model provides a fundamental matrix for the analysis of
classic sex problems and other subtle, but widespread, sex-related health
problems. Unfortunately, the lack of sexual fulfillment and confusion
about sex allows for much exploitation. There is no pill that will correct
the sexual positioning of partners or teach them to coordinate their
sexual movement. The CAT is quietly becoming a standard of the sex
therapist's regimen, internationally. But, those therapists adopting the
CAT may be fearful that they will be black-listed if they adopt and openly
acknowledge a natural cure for sex problems that largely obliterates the
need for drugs. (It is important to be mindful that FSD symptoms have
often been the side effects of pharmaceutical products.) Historically,
drugs have helped save the world from lethal pandemic diseases. It would
be tragic if Big Pharma becomes the CAUSE of the most universal health
problems in our time.
References
1. Nobile P. The new intercourse. Cosmopolitan 1991;211(no 3).
2. Moynihan R. The marketing of a disease: female sexual
dysfunction. BMJ 2005; 330 (7484):192-194.
3. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human
male. Philadelphia: WB Saunders, 1948.
4. Kinsey AC, Pomeroy WB, Martin CE, Gebhard PH. Sexual behavior in
the human female. Philadelphia: WB Saunders, 1953.
5. Eichel EW, Eichel JD, Kule S. The technique of coital alignment
and its relation to female orgasmic response and simultaneous orgasm. J
Sex Marital Therapy 1988; 14:129-141.
6. Pierce AP. The coital alignment technique (CAT): An overview of
studies. J Sex Marital Therapy 2000; 26:257-268.
7. Dickinson RL. Human sex anatomy (2nd Ed). Baltimore: Williams
& Wilkins, 1949.
8. Freud S. The justification for detaching from neurasthenia a
particular syndrome: The anxiety neurosis. Collected papers. London:
Hogarth Press 1894/1950; 1:97-98.
9. Reich W. (Trans. Wolf TP). The function of the orgasm. New
York: Farrar, Strauss & Giroux, 1942.
10. Masters WH, Johnson VE. Human sexual response. Boston: Little
Brown, 1966.
11. Eichel EW. Orgasm the natural way: The coital alignment
technique, 2001: Vers 1.0.
12. Zaviacic M. The human female prostate (English text). Slovak
Academic Press, 1999.
13. Zaviacic M, Zajickova M, Blazekoya J, Donarova L, Stvrtina S,
Mikulecky M, Zaviacic T, Holoman K, Breza J. Weight, size, macroanatomy,
and histology of the normal prostate in the adult human female: A
minireview. J Histotechnology 2000; 23(1):61-69.
14. Ablin RJ, Stein-Werblowsky R. Sexual behavior and increased anal
cancer. Immunology and Cell Biology 1997; 75:181-183.
15. Brody S. Concordance between women's physiological and
subjective sexual arousal is associated with consistency of orgasm during
intercourse but not other sexual behavior. J Sex & Marital Therapy
2003; 29:15-23.
Competing interests:
Producer of educational video: Orgasm the Natural Way - The Coital Alignment Technique
(2002) vers. 1.1
Competing interests: No competing interests