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Sex and Drugs: some thoughts about pharmaceuticals

Sex and DrugsIn response to “A Pill to Boost Female Libido” (NY Times 6-12-2015) and “I’m a feminist. Here’s why I don’t support the ‘female Viagra’” (Washington Post 6-8-2015)

Quest for the “Female Viagra”

Pharmaceutical companies have long been engaged in a quest for the “female Viagra,” a drug to treat female sexual dysfunction. Now an advisory panel, on an 18-6 vote, has recommended the FDA approve a candidate drug, flibanserin, made by Sprout Pharmaceuticals.

The drug is designed to modulate neurotransmitters thought to impact the sexual response. It aims to balance the excitatory activity of dopamine and norepinephrine with the inhibitory activity of serotonin in the brain.

In clinical trials of flibanserin, women who took the drug reported having approximately one additional sexually satisfying event per month over those who received the placebo. Potential side effects included low blood pressure, fainting, dizziness, and sleepiness.

This has been a highly politicized process, with some women’s groups (including Even the Score, backed by Sprout Pharma) hailing the committee recommendation, while others, such as the National Women’s Health Network, complain that safety concerns have not been adequately addressed.

I understand the excitement about the possibility of a simple, effective, and safe treatment for low desire in women. Low desire (in both women and men) is the most common reason for referral to sex therapy. Since Viagra came on the market in 1998 with much fanfare as the miracle drug for erectile dysfunction (ED), women have wished for a similar medication to help them with flagging desire. Unfortunately, it’s not that simple – for men or women.

No Magic Pill to Cure Sexual Ills

I’m reminded of the many male clients in my office over the years, discussing their efforts to address erection difficulties with Viagra, Cialis, or Levitra. Many complained the drugs did not help them, saying their erection difficulties persisted no matter which drug they used. Others were satisfied with the assist they got from the drugs. I have some skepticism regarding the possibility of a silver bullet for any sexual difficulty, whether male or female.

I’m troubled by our predilection to turn to a pill for a solution to a health challenge. There are other, less invasive or risky treatments that hold promise for good outcomes, and I am concerned when a pill is available these other treatments will not be investigated. Taking a pill at night is relatively simple. On the other hand, learning to communicate better with your spouse, or learning how to reduce your chronic stress levels, or exercising or changing your diet for better heart health, or learning to relax the chronic tension in your PC muscles all require significantly more time, effort, and commitment.

The pharmacological approach is primarily about ameliorating symptoms rather than addressing root causes. When ED drugs do not work, it is likely the underlying causes of the symptom are not being addressed. Marty Klein has a wonderful blog post on “erection disappointments”, where he lists ten reasons why a man might not get an erection when he would like to have sex. The reasons include too much alcohol intake, fatigue, worries about possible pregnancy, conflict with the partner, and feeling the pressure of time. WebMD offers a similar list of “sex-drive killers” that include stress, conflicts in the relationship, alcohol overuse, lack of sleep, parenting responsibilities, medication side effects, and poor body image. The factors on these lists cause or exacerbate low desire, erection difficulties, and other sexual dysfunctions. Addressing these causes is likely to reduce the presenting problem. But not everyone wants to work on it!

A man once consulted me for help with his persistent ED. He had repeatedly tried each of the drugs, none of which worked for him. He then found a urologist who implanted a penile prosthesis. When it did not work to his satisfaction, he had it removed and tried a different kind of prosthesis. When that was not satisfactory he turned to using alprostadil injections into his penis before attempting sex with his partner.

After he told me his saga of torturous medical interventions, I inquired about his relationship with his partner. “Well, I’ve been with her a long time, but I don’t really like her that much,” he replied.

I was stunned. This seemed like the logical place to explore some of the factors that contributed to his erection difficulties. He waved his hand to close off that discussion. “That’s just the way things are,” he said. He was not willing to include her in talking about his problems. He returned to see me twice more, then I lost contact with him.

Systemic Approach to Sexual Difficulties

While this is an extreme example, I advocate for a more systemic approach to treating sexual difficulties. It’s important to explore the stressors, conflicts, and cognitive-behavioral factors that contribute to the troublesome symptom that has brought someone to my office.

I am not against medical intervention when it is necessary, but I’m questioning the reflexive way in which we Americans place our trust in the latest pharmaceutical products. My goal as therapist is to gain a comprehensive understanding of a client’s problem, in a time-efficient way, so we can work together to create sustainable and satisfying outcomes. If medication is a part of that solution, great. If twenty minutes of meditation and a short walk and some hugs every day can shift some of the stressors and draw a couple closer to the type of intimacy they yearn for, then that couple can enjoy their relationship and feel empowered to deal with future challenges.

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