Whether or not women orgasm and how they orgasm has been the subject of speculation for thousands of years. The diagnosis of hysteria in women began with Hippocrates and has been associated with pathology in female sexuality and reproduction. Galen, another early physician, thought hysteria represented a lack of sexual gratification in women who were particularly passionate.
How much has the understanding of women's sexuality advanced in the last century? Are current medical understandings of female sexuality influenced by notions of how women should feel sexual pleasure? And, in this day and age of pharmaceutical marketing, are some trying to pathologize and hence, capitalize on the sexual difficulties of some women?
Filmmaker Liz Canner took on the subject of the female orgasm and pharmaceutical companies in her film 2009 Orgasm, Inc. I interviewed Ms. Canner regarding her film as well as a couple of well-known psychoanalysts on the topic of women's sexuality, the medicalization of female sexual desire and the perturbing idea of the "right" kind of orgasm.
Interview with Liz Canner
TMG: In your film Orgasm, Inc. you indicate that 43 percent of women aged 18-59 have some kind of sexual dysfunction (also known as Female Sexual Dysfunction or FSD). Sexual dysfunction, in this context, indicates lack of sexual desire and difficulty achieving orgasm. What is your opinion on these statistics?
LC: All over the media you hear that a shocking 43 percent of women suffer from female sexual dysfunction. I first heard this statistic when I was working for the pharmaceutical industry in the early 2000s and it surprised me. If so many women had female sexual dysfunction, why didn't my mother tell me about it, and why weren't my friends talking about it? In fact, I had not even heard of the disease until I took the job in the drug industry.
In Orgasm Inc., I investigate the history of the 43 percent statistic. It turns out that it was taken from a sociology survey that was conducted in the early '90s to find out what people's sex lives were like. It was never meant to measure the number of women with a disease. Using exaggerated statistics like 43 percent manipulates women. It also says to Wall Street that there is a large market for [a] drug [to treat it].
The media talks about female sexual dysfunction as if it always existed -- when in fact it was a term that came about in the late 1990s. When Viagra was released it was such a blockbuster drug for men that companies like Pfizer began to think that there was also a big market for Viagra for women. The problem was that in order to develop and test a pharmaceutical drug, the FDA required that there be a clearly defined disease. Pfizer and a number of other drug companies sponsored the first meetings on FSD. In the end, 18 of the 19 authors of the definition of the disease had ties to 22 drug companies. This definition was extremely broad: Almost any sexual complaint you have, whatever causes it, will fall into this disease category.
TMG: In your film, you cover extensively the race of drug companies to develop drugs to help women achieve orgasm. The race still appears to be in progress. Why do you think drug companies have failed to provide the Viagra for women?
LC: In Orgasm Inc., I followed the pharmaceutical industry over a period of nine years as they raced to develop a female Viagra. They kept claiming they were developing a magic bullet, but most of the products did not work much better than a placebo. In fact, when I filmed the hearing for Procter and Gamble's testosterone patch, Intrinsa, one of the doctors on the FDA panel suggested to P&G that they should consider developing a placebo instead because it worked almost as well and there were no side effects.
Unfortunately, many of the drugs under development have potentially horrific side effects including breast cancer and cardiovascular problems. Most of the drugs that I began following a decade ago either were not approved or they dropped out of the race because they did not work. It's interesting to note that the only thing that has been FDA approved for female sexual dysfunction is an over-priced sex toy.
TMG: The history of psychology and psychoanalysis, in particular, has speculated regarding the difference between clitoral and vaginal orgasm. Vaginal orgasm was thought to be superior. What do you make of these distinctions?
LC: One the most damaging sociocultural beliefs popularized by psychoanalysis and Sigmund Freud was that women were supposed to have fabulous vaginal orgasms every time they had (heterosexual) intercourse. We know now, from the groundbreaking work of Shere Hite in the 1970s, that this is not true. In fact, 70 percent of women need direct clitoral stimulation in order to climax. However, the thing about sexual experience is that our sense of satisfaction comes from our expectations. In other words, if the pharmaceutical industry, through their savvy marketing, can convince women that they should be having an orgasm every time they have intercourse then a lot of women are going to believe they have female sexual dysfunction.
TMG: For a long time, sex therapists have been suggesting simple ideas such as prolonged sexual stimulation for women before intercourse as a way to support women having orgasms. Additionally, there are other ways women can achieve orgasm, beyond intercourse. Why do you think there has not been more of a common sense approach applied to the difficulty some women have in achieving orgasms, especially as applied to heterosexual sex?
LC: It's interesting because on the one hand our society is obsessed with talking about female orgasms yet it refuses to teach the basics about how to actually achieve one. For instance, we don't talk about pleasure in a sex education class and teach about the clitoris. Let's face it, sex sells but honesty about sex doesn't.
TMG: In your film Carol Queen describes FSD as the "hysteria of this century." How do you think the medicalization of female orgasm and desire has impacted women today?
LC: Throughout history, medicine has pathologized women's sexuality in order to understand and control it. During the Victorian era, many women with sexual problems were diagnosed as hysterical. In our grandmother's time, women with low desire were said to suffer from frigidity. During the feminist movement of the 1960's and 70's, the pathologizing and medicalizing of woman's sexual experience was challenged and resisted. Terms such as nymphomania, hysteria and frigidity were no longer used. Recently, the clocks have been turned back. The condition of low desire is now called hypoactive sexual desire disorder (HSDD) and there are quite a number of drug companies racing to find a nose spray, pill, cream or patch to cure it. The risk is that many healthy women will falsely think that they are diseased when in fact they are perfectly healthy and normal. By the way, I find it very curious that they're working on a desire drug for women. Would anybody think to develop a desire drug for men?
However, it is important to note that some women do suffer from a real physiological problem when they experience a lowering of their sex drive. Radical hysterectomies and some anti-depressants affect libido. However, the majority of women do not suffer from a disease. For many of us, our libidos are influenced by everyday life experiences such as aging, our sense of body image, the health of our relationship, stress, and past sexual encounters, including a history of sexual abuse.
TMG: Your film raises important issues regarding interests of pharmaceutical companies in making Female Sexual Dysfunction a disorder that needs to be treated. You also remind us of an important moment in American history, when Ronald Reagan signed a bill into law allowing drug companies to directly advertise to consumers. Though we can easily fault pharmaceutical companies regarding the medicalization of FSD and can easily understand their financial motives, how do we understand the buy-in of women in thinking they need treatment for FSD?
LC: While I was making my film, I interviewed quite a number of thoughtful, intelligent women about their sex lives. However, their lack of sexual knowledge really concerned me. For instance, one of the women in my film, Charletta, participated in the clinical trial of a medical device called an Orgasmatron. She underwent painful surgery to have the device installed in her spine. It turned out that Charletta actually had no trouble having an orgasm, but wanted it to happen during sex with her husband in what she considered a "normal" way. She was thrilled when I told her that most women don't climax through intercourse alone.
According to Charletta, her idea about what her sex life was supposed to be like came from the movies. In our society, we're constantly bombarded with images in the media of fabulous sex and the message that we should have orgasms every time. This is just not accurate.
The doctor had told Charletta that she had female sexual dysfunction because she was not having orgasms during intercourse. I think this speaks to the risk of medicalizing something so subjective. It creates the temptation to take advantage of women's lack of knowledge. In addition, the idea that there's sexual dysfunction implies that there's a norm. There is no norm, no medical study that says women should be having five orgasms a month during intercourse or ten sexual thoughts a day in order to be healthy. If you create something that promotes an ideal that women should be living up to, it's quite dangerous. I think that all of us have complaints. I mean, who doesn't want to have an orgasm whenever they want?
TMG: Clearly, sexuality in men and women operate differently and are uniquely subjectively experienced. Do you think a male ideal of sexuality has been applied to women? If so, what can women do to feel comfortable regarding their own sexuality?
LC: In the press you read, "Men have their Viagra, women want theirs too." I'd love to know which PR firm came up with this slogan because it is very effective. The question is what do women need Viagra for? As I've mentioned, most of women's sexual problems are not caused by a physical medical condition but are the result of socio-cultural issues. So, I think the only way that most women will be satisfied with their sex lives will be if they can take a product that makes them feel comfortable about their bodies; that ends sexual abuse towards women; that creates equality in the workplace; that creates equality in relationships; that gives women good sex education so they can fully know about the clitoris and about how their bodies function.
Hysteria: A New Look at an Old Disease
Hysteria is a 4,000 year-old diagnosis that relates to women's difficulties with sexuality and overall physical and emotional functioning. Though Freud is credited with citing the vaginal orgasm as superior, there is a long history of men evaluating the sexual experience of women. The diagnosis of Female Sexual Dysfunction may reflect a form of modern day hysteria, in which sociocultural expectations threaten to define female sexual experience.
After seeing Orgasm, Inc., talking with experts, as well as considering my own patients, it became clear to me that women are not necessarily complaining about their sex lives. Rather, they seem to be responding to external ideals about what is normal. And this begs the question: Do women know what is normal?
The psychology of women has shifted in how women with sexual difficulties are viewed. Perhaps where psychoanalysts previously pathologized women's sexuality, medicine has continued, though now in the form of the complicated and intertwined influence of pharmaceutical companies. Two authors, and psychoanalysts, Karen E. Starr, Psy.D. and Lewis Aron, Ph.D., have written about the history of the misogynistic treatment of women in the history of medicine.
In regards to the history of psychoanalysis and women, they note: "Although women have far more of a voice in the 21st century than they did in the 19th century, our views of female sexuality are still indeed influenced by patriarchy...It is clear that many women (and men) are still confused about what happens 'down there'. It is also clear that we are still learning about female sexuality as it relates to female anatomy, and that what has traditionally been referred to as a vaginal orgasm is actually more complicated than what was once thought."
Indeed, the sexual response cycle for both men and women is complicated. Why is it so important to determine the kind of orgasm a woman has? The determination about the kind of orgasm as a predictor of psychological health persists. A 2008 article in The Journal of Sex Medicine claimed that women who have clitoral orgasms possess less mature psychological defenses.
Freud may have perpetuated an idea about the superiority of vaginal orgasms, but this is rarely a part of standard psychoanalytic practice today. Starr and Aron note, "Freud clearly had his own biases and misunderstandings. Psychoanalysis nevertheless gave many women the sense that having sexual feelings, being sexual creatures, was normal and acceptable. That was an important contribution for his time, and perhaps still for our own. And it led the way, by the 1920s and '30s for many of his colleagues to question and challenge his more limited and misogynistic assumptions."
The history of psychiatry, medicine, and psychoanalysis has been complicated and replete with sexist and confused ideas about the sexuality of women. Although psychoanalysis has moved beyond traditional Freudian ideas about what constitutes the "right" kind of female sexual experience, the pharmaceutical companies have picked up where Freud and early psychoanalysis left off. Unlike psychoanalysts, pharmaceutical companies have a much larger stake in the female orgasm. Whether or not this idea is born of patriarchy may not matter in which millions and even billions of dollars are at stake. For drug companies, the issue is more about dollars and cents than about stimulation and orgasm. Women who want a pill to help them achieve what is biologically normal may be taking a shortcut and may be cheating themselves out of a more genuine kind of sexual pleasure. On that note, it is anything but hysterical for women to demand more in terms of their sexual experiences.