A clear lesson from history: If anything in the DSM can possibly be misused, it will be misused. Whenever a profit is to be made by twisting the DSM, it will be twisted. The drug companies' aggressive marketing of sexual dysfunctions is a great case in point. The DSM-5 will give drug companies running room to continue their disease mongering of female sexual disorders, hyping this DSM diagnosis as a means of pushing pills.
I received the following alert from Tamara Kayali, a Postdoctoral Research Fellow at Novel Tech Ethics, Dalhousie University, and Field Editor of Bioethics Dissertation Reviews:
Dear Doctor Frances: I suggest adding Female Sexual Arousal and Female Orgasms Disorders (FSD) to your recent list of the ten most problematic diagnoses in DSM-5. These have been heavily and misleadingly promoted by the drug companies in an effort to convince women that they are lacking sexual satisfaction and can find it in a pill or nasal spray.
Previously proffered products all turned out to be ineffective duds, but as the Female Sexual disorders represent such marketing gold, the companies keep coming up with new contenders and new hype that women have a sexual disorder that needs treatment.
The aggressive and highly successful marketing of Erectile Dysfunction to sell Viagra offers a classic case of drug company disease mongering and a model of what they are also trying to accomplish by pushing the Female Sexual Dysfunctions. The advertisements suggested subliminally that "Erectile Dysfunction (affectionately nicknamed ED) lurks in every bedroom and that every man needs to have his handy insurance policy." Athletes and failed presidential candidates were recruited as shills to drive the message home in what amounted to a non-stop media blitz. It was hard to watch a football game in peace.
Buoyed by Viagra's unprecedented popularity and profitability, its manufacturer (Pfizer) decided to try to double the size of their market by bringing women into the picture. The advertising logic insisted that they must have sexual dysfunctions comparable to men's and would be equally susceptible to pill pushing for enhanced satisfaction and performance. Enter the effort to peddle Viagra to women.
But there was a problem with this grand scheme. Tests on women diagnosed with 'hypoactive sexual desire disorder' showed that Viagra ... well... flopped.
Not discouraged, Procter and Gamble entered the fray with the notion that perhaps a testosterone patch would be more effective and could replicate the Viagra marketing magic. This was tested and... well... the patch also went flaccid.
But now we have a new possible 'breakthrough' - Tefina, a testosterone-based nasal spray! Want to bet on its efficacy? But the marketing potential of female sexual dysfunction is so great that we can expect a never ending march of highly questionable contenders.
Does any of this make sense? Moynihan and Mintzes compellingly illustrate how FSD presents a classic case of Pharma disease mongering. Survey results were misleadingly massaged to suggest that FSD is a common problem for women. Bancroft found that men more often complained of physical difficulties to do with erection and ejaculation, whereas women more often complained of lack of interest or pleasure in sex.
Reasoning by analogy, let's consider the tenor of each complaint in turn, starting with 'lack of interest'. I have no interest in eating mushy peas (a British delicacy consisting of peas boiled and mashed beyond recognition). Yet I do not think that my lack of interest in mushy peas is evidence that there is something wrong with me. Further, I do not believe I should resort to taking something to make me want them. So why should it be any different for sex?
Consider next the concern about 'lack of pleasure'. I may be committed to eating green vegetables and include mushy peas in my diet in order to maximize variety, but may not get the 'buzz' or satisfaction out of it that I get from eating other foods, such as raspberries or dark chocolate. Should I then conclude that there is something wrong with me? Might I suffer from Mushy Pea Appreciation Disorder? Why everyone should get pleasure from eating mushy peas is not obvious to me. What if the peas could be cooked differently (less mushy perhaps), or what if there could be some kind of flavor enhancement, such as lots of butter or salt? Or, what if I liked a different kind of pea altogether?
Analogously, if a woman experiences a lack of interest or pleasure in sex (including failure to experience orgasm from sex) and finds this problematic, the problem may not be a biological or mental illness. Perhaps the relationship needs some adjustment or her man needs some skills training. Or maybe it is not a man she needs at all. A UK study found that one of the factors associated with women diagnosed with sexual dysfunctions was having homosexual desires. To make matters worse (for men anyway) a US study found that while only 29% of women reported that they 'usually' or 'always' experienced an orgasm during sex, twice as many (60%) reported it for masturbation.
So while it may be kind of scientists to attempt to develop a drug that enables women to gain more pleasure and satisfaction from sex, it would be even kinder to women to look into a drug that made men better at it.... or made them stop nagging women for it.
Thank you, Dr. Kayali. You have presented a lively and telling critique of how the DSM-5's "female sexual disorder" section is likely to be hyped and misused. I agree with your view that FSD is mostly a concoction of lusty males, sex disorder clinicians and researchers (mostly male) and drug company sales gurus.
Certainly there are some women who would like to have more sexual interest and easier orgasms, and diagnosis and treatment may sometimes be useful for them. But the disease mongering pitch attempts to stretch this small market into a giant one by implying that sexual
dysfunction is a fairly ubiquitous part of being female, and this is simply nonsense.
Two closely related facts: The U.S. and New Zealand are the only developed countries in the world that allow drug companies to advertise directly to consumers, and the U.S. uses more unnecessary drugs than any other country. The solution is simple: Get into line with everyone else and end all this misleading advertising. This would happen in a minute if Pharma didn't have such a strong lock on politicians.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.