What Really Impacts Female Sex Drive?

This article originally appeared in the Medium publication “Ask Me About My Uterus” on November 8, 2015. You can read it in its original form here.

In August, news that the FDA had approved the prescription and sale of flibanserin — a drug originally pitched as an antidepressant — for the treatment of Hypoactive Sexual Desire Disorder (HSDD) in women sparked a national discussion about the drug’s safety, benefits and effectiveness. It also raised questions about gender bias in the medical world.

Flibanserin had a controversial stint in the limelight, having been put forth for FDA approval a total of three times before the August ruling. Critics pointed out that it quells the demand for drugs to treat low sexual desire in women with a major trade-off. It’s not very effective and has potentially serious side effects.

The causes of low female libido are nuanced and diverse, with probably as many unique contributing factors as there are women dealing with the problem. But the approval and sale of flibanserin for this purpose — likely to be a lucrative endeavor for its developer, Sprout Pharmaceuticals — made me wonder: What other treatments are at the forefront of female HSDD and low-libido research?

If we were to really get serious about helping women pursue happy and healthy sex lives in the way that we have helped men achieve that goal, what would it look like?

What is Flibanserin?

Flibanserin activates receptors of the neurotransmitter, serotonin, which is associated with happiness and contentment. This mechanism is common in the treatment of depression.

But because flibanserin wasn’t shown in trials to be effective for that purpose, Boehringer Ingelheim Pharmaceuticals repurposed the drug for the treatment of HSDD in 2010. The application was rejected due to flibanserin’s small demonstrable benefits and risky side effects.

Sprout Pharmaceuticals tried again in 2011, but was also rejected, with the FDA citing a need for more comprehensive studies about the drug’s safety and effectiveness.

Addyi, Sprout’s trademarked name for flibanserin, finally won FDA approval for the treatment of HSDD in August 2015. In trials, women reported having, on average, one additional “satisfying sexual event” per month while taking flibanserin — a total of 12 encounters per year.

Considering the drug’s potentially dangerous side effects, including fainting, severe low blood pressure, dizziness and loss of consciousness, many have questioned whether or not the drug’s potential benefits outweigh its risks. It is also worth noting that the participants didn’t report any actual increase in sexual desire — just a very modest increase in the frequency of sexual events.

The Demand for Libido-Boosting Drugs for Women

For years, well-meaning activists and organizations had been demanding treatments for low libido in women.

According to Even the Score, an organization dedicated to parity in sexual dysfunction treatments, the FDA has approved 26 drugs for the treatment of male sexual dysfunction; Addyi is the first drug of its kind to be approved for females.

This has earned Addyi the misleading moniker “female Viagra,” even though the two drugs have little in common in terms of their effects on the body. Viagra increases blood flow to the penis, while flibanserin affects brain chemistry.

It makes sense that we should be paying more attention to female sexual dysfunction. One in 10 women is diagnosed with HSDD, according to Even the Score, and countless more report disappointing sex lives and low sexual desire. Feminist thinking believes that we should, of course, be helping women pursue fulfilling sex lives in the same way we have helped men.

But given flibanserin’s dismal record of success and risky side effects, we must ask the question: Is this new drug, at best, a profitable, yet ineffective treatment, and, at worst, a red herring?

Research has shown that Addyi’s capacity for boosting sex drive is meager at best. It also doesn’t address the needs of millions of pre-menopausal women who aren’t diagnosed with HSDD, but suffer from low libido for other reasons.

The Paradox of Hormonal Birth Control

Hormonal birth control is thought to contribute to low female libido on a massive scale. The CDC reports that four out of five sexually experienced women (that is, women who have had sex) have used the pill during the course of their lives. Unfortunately, few women are educated on the pill’s biological effects when they decide to seek a prescription.

“When I asked Dr. Peter Bowen-Simpkins, a gynecologist and spokesperson for the organization Wellbeing for Women, why GPs do not fully explain the pill’s actions to their patients, he replied, ‘Why wouldn’t you be satisfied with just knowing it stops you producing eggs so you don’t get pregnant?” Holly Grigg-Spall writes in her book “Sweetening the Pill.”

What many women may not know is that the birth control pill releases a stream of synthetic hormones that are similar to those secreted by a woman’s body during times when ovulation would be physically problematic, such as pregnancy and the luteal phase of a woman’s monthly cycle. By mimicking this biological state, the birth control pill inhibits the maturation and release of eggs from the ovaries. Without ovulation, of course, conception cannot take place.

But this also suppresses the release of androgens (the most notable of which is testosterone) in the female body, and evens out the ebb and flow of monthly hormonal changes. Reduced androgen levels are responsible for some of the so-called extra benefits of the pill, such as clear skin. However, testosterone in particular is also closely linked with libido, and its suppression results in low sex drive in many women.

Additionally, flattening out cyclical hormone fluctuation results in a loss of the sexual peaks many women experience throughout the month. Low libido is just one of the unwanted side effects of the pill. Many women report feeling anxious, panicked and depressed while taking hormonal birth control. The same CDC study noted that 63 percent of women who went off the pill did so because of its unwanted side effects.

While few can argue the pill’s important role in women’s liberation, more and more people in both feminist and medical circles are turning their attention to the pill’s impacts on mental, sexual and emotional health. Many women have become interested in the Fertility Awareness Method (FAM). To be clear, this is not the Rhythm Method. Unlike the Rhythm Method, which assumes that fertility windows are based on a generic (and often irrelevant) 28-day cycle, FAM requires careful inspection of the body for basal temperature, cervical quality and other fertility signs.

Women who choose fertility awareness for non-religious reasons often combine the method with condoms and spermicide during fertile times of the month. Most sources award FAM a success rate of 95–99 percent when used correctly, making it more effective than condoms in many cases.

While natural methods may not be right for everyone, they are at least worth discussing, especially for premenopausal women suffering from low libido. The lack of attention to this generally reliable method is unfortunate, especially considering that we are turning to mood-altering drugs to boost an instinct that is often dulled by hormonal medications in the first place.

Trying to ‘Have It’ While Having it All

The American Psychological Association reports that women are much more likely than men to report elevated stress levels; and married women are more likely than single women to report physical symptoms of stress, such as nausea, headaches and insomnia. Women with children commonly report a decrease in sex drive, and many attribute the stress to fatigue, lack of sleep, relationship problems, and financial issues regarding work and childcare.

The correlation of stress to libido may be why the medical industry is so quick to promote antidepressants for the treatment of HSDD. However, getting to the heart of the issue may be a better strategy. Access to affordable childcare, paid parental leave, family-friendly workplace policies and preventative treatments for anxiety and stress may be more effective for reducing stress in a long-term, comprehensive way. It remains true, for example, that the United States is the only developed country not to offer paid parental leave to women after the birth of a child.

Physical Barriers to Sexual Pleasure

While Viagra makes sexual pleasure and intercourse possible by increasing blood flow to the penis, Addyi boosts desire by changing brain chemistry. However, there are physical barriers to pleasurable sex for females, too. ACOG states that about three in four women will report pain during sex at some point in their lives.

A common reason for this pain is vaginal dryness, which is usually a pretty quick fix. More severe causes of pain include vulvodynia (pain of the vulva with no identifiable cause) and vaginismus (spontaneous and painful vaginal contractions during intercourse).

Both of these conditions are suspected to be linked to anxiety during sex, which the ACOG claims can be related to relationship problems, feeling uncomfortable with one’s partner and — perhaps most chillingly — feeling “fear, guilt, shame and embarrassment” about sex. This kind of anxiety, and the painful physical response that often accompanies it, might be quelled by depression and anxiety medications, but that tactic begs the questions: Shouldn’t we be providing deeper help for women who feel such anxiety? Should the goal really be more sex?

Still more women suffer from physical sexual dysfunction after the birth of a child. Jane Marie described her vaginal reconstruction experience in an article for Jezebel. According to her OB/GYN, about 30 percent of women who give birth vaginally suffer from physical postpartum dysfunction. Vaginal prolapse, episiotomies and chronically weakened pelvic floor muscles can all negatively impact mothers’ sexual function and desire, not to mention quality of life.

The medical establishment’s concern for female sexuality only goes so far, of course. As Jane Marie so aptly observes in the closing of her article:

“You want to know how much this cost and whether insurance covers it, yeah? It’s $10,000 — the price of a used car — and no, insurance does not cover it,” she says. “Having scarring from tears during childbirth and atrophied muscles from pushing do not count as real medical issues, but instead are considered cosmetic complaints. Meanwhile, there’s Viagra. Fuck the patriarchy.”

Flibanserin: A Jumping-Off Point

I’m not suggesting that antidepressants are bad, and I’m sure many women will probably benefit from the use of Addyi. It’s also worth noting that women dealing with some of the factors I’ve mentioned are not ideal flibanserin candidates. Addyi is not meant to be used for the treatment of low libido due to relationship factors or stress. It’s specifically meant for the one in 10 women diagnosed with HSDD.

Still, if the medical establishment wants to take a real, honest look at female sexuality, we can’t forget about the roles of hormonal contraceptives, workplace policies and physical complications. Women deserve to be educated about contraceptive options that won’t alter their moods or sex drives. They deserve to enjoy paid leave after giving birth so they can heal and spend time with their babies, without losing sleep over finances — as so many women all over the world do, but American women, sadly, do not. They deserve mental health care that enables them to deal with anxiety and sexual trauma. They deserve for birth-related muscular atrophy and an absence of vaginal and/or vulvar pleasure to be treated as medical conditions and quality-of-life issues.

If we can use the approval of Addyi as a jumping-off point to include sexual health issues like these in our approach to women’s health care, that’s a start. But let’s make sure it isn’t the end of the conversation.