What women want

For women who've lost that loving feeling the idea of a physical fix is very seductive. But is it the answer, asks Diane Martindale

AT 45, Betty Connelly* had never had an orgasm. Over the years, countless therapists had probed her mind, searching for dark, deep-rooted problems that deprived her of sexual pleasure. They found nothing. Meanwhile, Betty's sex life waned, her husband had an affair and her marriage ended. Frustrated, she swapped the psychiatrist's couch for a urologist's examination table and the mystery was solved: a flap of skin was fused over her clitoris. With the skin removed, Betty should finally enjoy sex to the full. For Betty, sex therapy alone was about as useful as a cold shower-her problem was physical. But her experience typifies a new approach to female sexual woes that has come hard on the heels of Viagra. Ever since Pfizer unleashed the little blue diamond in 1998 and revamped the male sexual landscape, doctors and researchers-not to mention pharmaceuticals companies-have set their sights on finding physical causes for women's sexual problems. So-called "female sexual dysfunction" (FSD), they say, is a physical disorder that is measurable, diagnosable and ultimately treatable with drugs, gadgets or surgery.

The more traditional sex therapists, however, are defending their hard-won ground. The quick physical fix is doomed to fail, they say, because it ignores a grim reality: in their view, most women's sex problems stem not from physical or medical problems but from their social or cultural situation, poor relationships and emotional factors.

Even the term FSD is contentious. When, in late 1998, a consensus panel set up by the American Foundation for Urologic Disease met to thrash out definitions for different types of FSD (see "Female sexual dysfunction", page 31), they included an addendum that was widely interpreted as a bid to placate traditional sex therapists. They conceded that a woman only has FSD when her problems cause her personal distress.

What everyone does agree is that there is a big problem. In 1999, the most definitive study of sexual practices in the US to date reported that an alarming 43 per cent of women, young and old, had problems with their sex lives (Journal of the American Medical Association, vol 281, page 537). If everything is working properly, when a woman is turned on, nerve messages from the brain tell specialised smooth muscle in the clitoris and labia to relax. This creates cavities that fill with blood and make the clitoris erect. Blood floods into the muscular wall of the vagina, making it swell, and encouraging fluid to seep from the capillaries into the vaginal cavity. Messages from the brain also tell glands inside the vagina to secrete gelatinous mucus. With the right stimulation things only calm down again when she's had an orgasm.

In women with female arousal disorder, the clitoris and vagina fail to engorge with blood. The result is that sex, let alone orgasm, can be impossible. Viagra works in men by slowing the breakdown of nitric oxide, the substance that relaxes smooth muscles in the penis so that erectile tissue can fill up with blood. Since nitric oxide is also present in female genital tissues, doctors reasoned that the drug should help women too.

The early prognosis for Viagra for women, though, is less than thrilling. In one study, roughly half of 577 women tested reported an increase in genital sensation, lubrication and overall arousal. But the successes were equally split between the women taking Viagra and the control group. "This says that placebos are pretty good at improving sexual function," says Rosemary Basson, a sexual medicine specialist at the University of British Columbia in Vancouver who ran the Canadian arm of the Pfizer-funded trial.

But it may still be too early to write off Viagra for women. One big problem with the study, say Basson and others, is that only 46 per cent of the women had arousal disorder. Viagra may not be able to help with other types of FSD such as low libido, so it's important to test the drug only in women who still have a desire for sex but complain that it doesn't feel as good as it used to, says Basson. Pfizer has begun just such a study.

Viagra could also work for women with spinal cord injuries, or nerve damage due to surgery or multiple sclerosis. In these women, the message from the brain to the genitals can be weakened, which often makes arousal and orgasm impossible. Viagra, which has already shown its mettle in men with spinal cord damage, can help amplify that signal, says Marca Sipski, chief of the Spinal Cord Injury Service at the Miami Veterans Administration Medical Center.

Last year, Sipski ran a placebo-controlled pilot study with Viagra in 19 pre-menopausal women with spinal cord injuries. The women were given Viagra or a sugar pill and asked to masturbate while watching an erotic video. All the women who got the drug experienced an increase in genital blood flow and arousal, with one woman managing full orgasm. The women who took the sugar pills never got off the starting blocks.

But there may be better ways to treat arousal disorder-which often includes an inability to produce enough mucus and to relax the smooth muscle of the vagina. "Compounds that target only erectile tissue miss half the boat," says Joe Podolski, president of Zonagen in The Woodlands, Texas, the maker of a sex drug called Vasofem, which works in a different way from Viagra.

Vasofem contains phentolamine, which first hit the clinical trial circuit as Vasomax for men. In healthy men, adrenaline damps down the effect of nitric oxide, stimulating smooth muscle to constrict and restricting blood flow to the penis-preventing men sporting day-long erections. Because phentolamine blocks adrenaline, it can help men keep a temperamental penis erect. The drug might also work in women. In two studies in American and Mexican clinics, nearly 200 women taking Vasofem had improved clitoral and vaginal blood flow, lubrication and sensation. Results from a home-based study in Mexico are expected later this year.

But Vasofem may have a nasty side. Phentolamine is associated with benign tumours called brown fat proliferations. Podolski insists that the effect is "rat specific", and is only spotted in rats getting a daily dose of the drug. Most people would only take it a few times a month. What's more, he says, none of the men in the earlier trials developed tumours. "However, there is erectile tissue in the nose, so our biggest complaint is a stuffy nose," he says. Nonetheless, the US Food and Drug Administration has put further Vasofem trials in the US on hold.

Drugs, however, aren't the only potential stairway to heaven. A device approved by the FDA last year, and designed for women with arousal difficulties, is the Eros-CTD or "clitoral therapy device" developed by UroMetrics in St Paul, Minnesota. Eros looks like a doll-sized oxygen mask attached to a hand-held battery pack. Slipped over the clitoris, it simulates the experience of oral sex, providing a gentle suction to stimulate blood flow. It's not meant to replace the vibrator, but it does induce orgasms in some women. So good are these little pumps, claims the company, that women refused to give them back once the clinical trials were finished.

And more high-tech devices for reaching orgasm may be coming to a doctor near you in the future. Later this year, Medtronic, another Minnesota-based company, expects to start testing a remote control device that is surgically connected into nerves of the spinal cord that trigger orgasm (see New Scientist, 10 February, p 23).

Sex therapist Leonore Tiefer at New York University School of Medicine in New York City is unimpressed. Whether you use a pill, suction cup or implant, the whole business of treating female sexual problems only from a physical standpoint is nonsense, she says. For a start, there is the sheer number of women who suffer from FSD. If almost half the population has the disorder, is it more likely that they all suffer from some physical defect, or that there is a societal or cultural problem that needs to be addressed, Tiefer asks.

Strangely enough, the drugs trials seem to support the idea that sexual problems are often caused by something other than a physical defect. Think back to that Viagra trial, where a sugar pill was just as effective as the real thing when it came to treating FSD. The result "emphasises the multifaceted character of FSD", admits Basson. Taking a pill motivated the couples to get the context right, to get the closeness right, to take the time and expect things to be better. "All of that is just as important as what you put in the mouth," she says.

Tiefer doesn't pretend to be able to change society overnight, but she firmly believes that sex therapy can give many women what they want-without having to resort to drugs. Sex therapy usually involves a combination of practical tips on sexual techniques, psychotherapy to help the patient work out what makes sex enjoyable and meaningful to her, and advice to redefine sexual goals away from counting orgasms. And although there have been no controlled studies investigating how successful therapy is, anecdotal evidence suggests that it works for some.

Still, many people are embarrassed to even mention sex to their doctors let alone to subject themselves to emotionally taxing sex therapy. Much simpler to ask for a pill. "By reducing women to body parts and promoting orgasm-oriented sex, drug companies take advantage of the poor sex education in the US," says Tiefer.

Carol Ellison, a clinical psychologist in Oakland, California, agrees and says that pill pushing is an attempt to ignore the obvious fact that today's women are simply overburdened. For her book Women's Sexualities, she surveyed more than 2600 American women: those who reported sexual problems did not usually associate them with anything physical, but with lifestyle issues, such as being too tired and too busy, running homes, raising children and working full-time. "No little thing that pulls on your clitoris and gets it erect is going to cure that," she says.

To Ellison, pushing pills to alleviate women's dissatisfaction with their sexual lot makes about as much sense as prescribing sedatives to housebound women while limiting their access to meaningful employment, as was done back in the 1950s.

Drugs are not even the answer for older couples-those who are most likely to have experienced the physical changes that make erections for men and arousal for women increasingly unreliable, she says. Ellison's mantra is "sexual self-acceptance", and for older couples that can mean coming to terms with the idea that caressing and sex talk will replace intercourse and orgasms. "Now that men take Viagra, women need to take their own pill," Tiefer mocks. "So he's got a 20-year-old penis and she's got a 20-year-old vagina and they go bankrupt. This is not the ideal for sex between older people."

Besides depleting the retirement fund, and bringing the risk of side effects, sex drugs can have a negative impact even when they have the hoped-for physical effects, suspects Erick Janssen, a psychologist and researcher at the Kinsey Institute for Research in Sex, Gender and Reproduction in Bloomington, Indiana. Anecdotal evidence suggests that couples may expect too much from Viagra, and be sorely disappointed when they discover that the ability to have intercourse doesn't necessarily rejuvenate a relationship in other ways.

Janssen is setting up a study of 50 couples that is designed to identify the pros and cons of using Viagra, as well as what types of relationships are most likely to benefit from the drug. "I'm not against the drug approach," says Janssen. "But it has the potential of something that is getting out of hand."

Those sorts of attitudes seriously undervalue the benefits of drugs, says Laura Berman, a sex therapist who, along with her sister, urologist Jennifer Berman, runs the Female Sexual Medicine Clinic at the University of California in Los Angeles. She points out that identifying physical causes of FSD has come on in leaps and bounds since the "dark ages" of the pre-Viagra 1990s when traditional sex therapy gained its foothold. Back then it was not uncommon for doctors to ask a woman only whether she could have sex without pain. "If the answer was yes, then she was sexually functional," says Laura Berman, "No one ever bothered to ask her about orgasms or if she enjoyed sex." Women who wanted treatment for a sexual problem usually had no choice but to opt for the talking cure.

Nowadays, doctors who specialise in sexual health may have at their disposal a battery of high-tech gadgets to tease out underlying physical causes of sexual dysfunction. In a typical visit to the Bermans' clinic, an ultrasound probe resembling an electronic tampon is inserted into the patient's vagina to measure blood flow, a pH probe measures alkalinity, which fluctuates depending on the amount of lubrication, and a third probe measures changes in the length and width of muscle tissue. A biothesiometer is used to determine the sensitivity of the clitoris and labia to applied pressure, heat and cold. Readings are taken before and after stimulation with porno flicks and vibrators, and before and after a patient receives drug treatments. A lengthy psychological examination is always part of the diagnosis.

With the information gleaned, the Bermans can decide on a course of treatment. Occasionally, they will recommend traditional sex therapy. But most of the women who come to their clinic have already explored that route and found it wanting, so treatment more often involves some combination of sexual enhancing devices like the Eros-clitoral therapy device, surgery or drugs.

Of all the sexual disorders, low libido is the one that is often clearly linked to psychological or emotional causes, including stress, fatigue and depression-especially among younger women. But even here, doctors are increasingly relying on interventions that are designed to tackle physical problems.

It turns out that testosterone, which has long been known to turbocharge men's sex drive, may be just as important in women, says Laura Berman. "It's common to test oestrogen levels," she says, but clinical practice suggests that "testosterone is so central to a woman's sexual function that no lover or amount of sexual stimulation can make up for its absence".

Testosterone levels plummet in post-menopausal women, so it makes sense to use the hormone to treat desire and arousal disorders in this group. However, doctors are also claiming success with younger women. But it may be too soon to start handing out testosterone to all and sundry, warns AndrŽ Guay, an endocrinologist and director of the Centre for Sexual Function at the Lahey Clinic in Peabody, Massachusetts. "We don't have an accurate way of measuring [testosterone] and we still haven't figured out the normal range in healthy women."

Others warn that testosterone treatment may increase women's risk of liver and heart disease, raise cholesterol to dangerous levels, and have side effects such as increased hair growth on the face. But it may be possible to avoid some of these side effects by giving testosterone via skin patches rather than pills. When researchers at Cedars-Sinai Medical Center in Los Angeles gave post-menopausal women testosterone via an abdominal skin patch, the women reported an increase in libido and sexual function without nasty side effects such as extra hair growth and weight gain (The New England Journal of Medicine, vol 343, p 682).

Low testosterone levels may even be to blame for Viagra's poor results in some women, suggests Irwin Goldstein, a Boston University urologist. In a study of female rats, Goldstein discovered that lowering their testosterone levels completely blocked relaxation of the smooth muscle in their genitals, even when the rats were given Viagra. Other Viagra studies have reported a high failure rate in men with low testosterone levels.

Goldstein, who runs the Women's Sexual Health Clinic in Boston, now gives many of his pre and post-menopausal patients dehydroepiandrosterone (DHEA), a precursor to testosterone, either alone or in combination with Viagra. "With DHEA, the Viagra response is wonderful and similar to men's," says Goldstein. "I can now look a woman in the eye and say 'I have at least a 50 per cent chance of curing you'."

And so the battle lines are drawn. On the one side, doctors like Goldstein and Berman are prepared to use all the drugs and gadgets at their disposal in their bid to improve women's sexual lot. On the other side, Tiefer has joined forces with over a dozen other therapists across the US and Canada to set up the Working Group on A New View of Women's Sexual Problems. The group stresses the belief that women's sexual problems usually stem from social, cultural or emotional factors. It hopes to persuade women to listen to someone other than the drugs companies, and to make the space to try sex therapy as a way of solving their problems.

Laura Berman is not convinced. "This is the view that I was trained on," she says. "Sex involves emotional, physical and sociological components, that's nothing new." And while Berman agrees that there is too much pressure on women "to be swinging from the chandeliers every time they have sex", that, she says, is not the point of treating FSD like any other curable disorder. It's about controlling your own sexuality.

"We are not saying orgasms are necessary for a woman to be a real woman or to have a certain quality of life," says Berman. "We are just saying that every woman is entitled to an orgasm if she wants one."

Diane Martindale is a science writer based in New York City

New Scientist issue: 17th March 2001 PLEASE MENTION NEW SCIENTIST AS THE SOURCE OF THIS STORY AND, IF PUBLISHING ONLINE, PLEASE CARRY A HYPERLINK TO: http://www.newscientist.com