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BMJ. 2003 March 22; 326(7390): 658. | PMCID: PMC1125553 |
The making of a disease: female sexual dysfunction Without industry funding little new research will be possible Rosemary Basson, clinical professor Department of Psychiatry, University of British Columbia, BC Centre for Sexual Medicine, Vancouver Hospital, 855 W 12th Avenue, Vancouver, BC, Canada V5Z 1M9 Email: sexmed/at/interchange.ubc.ca Sandra Leiblum, professor of psychiatry Department of Psychiatry, UMDNJ—Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, New Jersey, NJ 08854, USA Email: leiblum/at/umdnj.edu Editor—Moynihan wrote about female sexual dysfunction as a disease in the making. 1 As co-chairs for an (unpaid) international committee, commissioned and supported by the American Foundation of Urological Disease, to improve definitions of women's sexual dysfunction, we regret the sensational biased view of industry funded research of biological components of women's sexual function. The common error of equating self reported sexual problems with medically diagnosable disorder is well recognised. However, to focus only on this and neglect the need for research into aetiology, pathogenesis, and treatment of women's sexual dysfunction from disease, medical, and surgical interventions, is unfortunate. To date, neither the major neurotransmitter involved in vaginal congestion nor the autonomic innervation of the vulval structures has been established. Industry funding facilitates research of interrupted sexual responses from chemotherapy, pelvic surgery, neurological disease, premature menopause, and drug treatment, as well as healthy sexual physiology. We question the concept of a “new definition of human illness.” Women's sexual dysfunction has been diagnosed throughout the centuries. The committee meeting in 1998 tried to modulate definitions in the American Psychiatric Association's Diagnostic and Statistical Manual of Disease, to be more reflective of women's sexuality and did not create “new disorders.” However, the formulation of accurate diagnosis is a continuing process—what is “normal” for women of different ethnic, religious, and cultural backgrounds, and of different ages and life stages is still unclear. Women's sexual function is highly contextual; many aetiological factors—physical, psychological, and interpersonal—must be not only evaluated but included in the diagnosis. Thus the definitions are becoming less rather than more medical. Without accurate definitions of dysfunction, any potential contributory role for pharmacotherapy in holistic management of dysfunction cannot be explored. Without support from the pharmaceutical industry, little new research into sexual physiology is likely or the means by which psychological factors alter the biological processes involved. 1. Moynihan R. The making of a disease: female sexual dysfunction. BMJ. 2003;326:45–47. . (4 January.). [PubMed]
Diversity of experiences should be acknowledged Annie Potts, Health Research Council research fellow Gender Studies, University of Canterbury, Private Bag 4800, Christchurch, New Zealand Email: annie.potts/at/Canterbury.ac.nz Editor—I have followed the debate on female sexual dysfunction sparked by Moynihan's article with interest. 1-1,1-2 I agree more attention should be paid to women's sexual concerns. I argue, however, that it is crucial to acknowledge the diverse experiences and viewpoints of women on what constitutes “normal,” “healthy” sexuality, and pleasurable sexual intercourse for them—rather than have these matters predetermined by a biomedical and pharmacological model of sexuality. My colleagues and I conducted an indepth qualitative study, funded by the Health Research Council of New Zealand, on the social impact of sexuopharmaceuticals. We asked women and men about their experiences of sexual difficulties—and men's use of Viagra (sildenafil citrate)—in relationships. Participants' accounts of sexual experiences and pleasures were diverse (this finding itself disputes any generalisation about “normal” female and male sexuality). Of relevance to this debate were the perspectives of those who enjoyed sexual relationships when erections were absent; contrary to medical assumptions about sexual dysfunctions, they did not subscribe to the view that changes in erections (particularly those associated with ageing) were abnormal or dysfunctional. Importantly, some felt pressured to comply with normative ideas about female and male sexuality by partners, doctors, and sexuopharmaceutical advertising campaigns; and a few commented that it was drug company advertising that prompted them to feel anxious in the first place about their own sexual performances. We should therefore be concerned about creating “new” types of sexual problems and performance anxieties in this way. The diversity of experiences and viewpoints in our study challenges any model that would reduce normal or healthy sexuality to certain goals or behaviours, or to basic physiological processes that can be manipulated by chemicals. Sexualities—women's and men's—are more complex and unpredictable than the biomedical model implies; more attention should be given to the impact of social, economic and political factors on sexual desires, pleasures, and behaviours. 1-1. Moynihan R. The making of a disease: female sexual dysfunction. BMJ. 2003;326:45–47. . (4 January.). [PubMed]
Conspiracy of silence hinders understanding Pauline Lewis, patient Welwyn, Hertfordshire AL6 0XB Email: paulineeglewis/at/uk2.net Editor—Female sexual dysfunction is a real and distressing problem for millions of women. 2-1 It can be a result of surgery, antidepressants, hormone treatments, and the menopause. If a woman overcomes her embarrassment enough to complain she is effectively silenced by the constant response that it is psychological (she is imagining it), it does not happen, and there is no physical explanation for what she is reporting. Her complaint is met with incomprehension and incredulity. Very little understanding and even less help are available out there—even if her doctor is sympathetic there is nothing to offer. In short, she must put up with it and accept that sexual pleasure is finished for her. She is forced to be just one more participant in the conspiracy of silence. 2-1. Moynihan R. The making of a disease: female sexual dysfunction. BMJ. 2003;326:45–47. . ( 4 January.). [PubMed]
Inaccuracies are not helpful Declan P Doogan, senior vice-president Sandwich Laboratories and Japan Development, Pfizer Global Research and Development, Sandwich, Kent CT13 9NJ Email: Declan_Doogan/at/sandwich.pfizer.com Editor—Moynihan alleges that the pharmaceutical industry influences independent researchers to create a new medical disorder. 3-1 His inaccuracies and false allegations are not informative or helpful to researchers and clinicians or women with sexual dysfunction. The literature documented the dysfunction well before pharmaceutical companies began investigating treatments. In 1992 the International Classification of Diseases and related health problems described and defined female sexual dysfunction. 3-2 The 1994 American Psychiatric Association's Diagnostic and Statistical Manual provided comprehensive definitions of the various types of it. 3-3To say that definitions of female sexual dysfunction are being criticised as misleading and potentially dangerous is disingenuous, based on a few opinions, rather than consensus. In the previous issue Stone et al noted the difficulty in defining health and disease. 3-4 This observation is accurate for complex and overlapping conditions such as female sexual function. Consensus meetings are appropriate to agree on definitions and classifications and refine these with additional epidemiological, psychological, and clinical research. Moynihan fails to note that these meetings included academic researchers, clinicians, and sexologists who treat sexual problems as well as regulatory agency experts. Independent experts who see patients lead the discussions. We suggest the BMJ publishes the 1994 classification and definitions of various types of female sexual dysfunction, and the meetings' revised classification and definitions, for the readership to judge whether “a new medical disorder” has been created. The BMJ 's trivialisation of a distressing dysfunction and its cynicism about an ethical pharmaceutical company's activities and those of the independent experts are unfortunate. Our research efforts often are published and widely commented on. The data can sometimes be controversial but occasionally may lead to advances whereby regulated treatments—pharmacological and other—can be legitimately prescribed. 3-1. Moynihan R. The making of a disease: female sexual dysfunction. BMJ. 2003;326:45–47. . ( 4 January.). [PubMed] 3-2. Cooper JE, editor. Pocket guide to ICD-10 Classification of Mental and Behavioural Disorders with Glossary and Diagnostic Criteria for Research DCR-10. Edinburgh: Churchill Livingstone; 1992. pp. 208–217. 3-3. American Psychiatric Association. Diagnostic and Statistical Manual (quick reference to the diagnostic criteria from DSM-IV). American Psychiatric Association. 1994. pp. 233–237. . (Chapter: Sexual and gender identity disorders.). 3-4. Stone J, Wojcik W, Durrance D, Carson A, Lewis S, MacKenzie L, et al. What should we say to patients with symptoms unexplained by disease? The “number needed to offend.” BMJ. 2002;325:1449–1450. . (21-28 December.). [PubMed]
Summary of responses Alison Tonks, associate editor BMJ Editor—Within six weeks of publication of Ray Moynihan's article we had received 70 responses, 26 of them overtly critical. 4-1,4-2 The most strident were from women who thought that the article was denying the existence of female sexual dysfunction, so denying help to thousands of women with real and treatable sexual problems. “It gets very tiring defending the reality of female sexual dysfunction and the need for research,” wrote one. “It is because of physicians and journalists like this one that so many women with FSD [female sexual dysfunction] have been suffering in silence for so long.” Another wrote, “Most practitioners are still working under the paradigm that all sexual problems are the result of psychological problems, a faulty relationship, or a careless partner. There are a significant number of women who experience physically based sexual dysfunction, and their needs can only be met by doctors who know how to recognise and treat (or refer) appropriately.” Letters from sexual health specialists echoed these sentiments. Most said they understood the complexity of their patients' needs and rejected a narrow biomedical view of sexual dysfunction. Most also agreed, though, that chronic illnesses such as diabetes, drugs, and surgery, particularly pelvic surgery, can all cause serious sexual problems in women. They and others complained of our woeful ignorance of women's sexuality, and by extension anything that goes wrong with it. How can we know what is wrong, when we don't know what is right? Respondents with biomedical backgrounds mentioned ignorance of women's basic anatomy, physiology, and biochemistry. Those with more sociological or psychological perspectives said that we don't know what's “normal” because no one has bothered to ask a representative cohort of women. A consumer advocate from New York asked “Do we want surgeons (urologists, gynaecologists) defining sexual dysfunction? More to the point do we want drug industry funded surgeons defining sexual dysfunction?” “What passes for knowledge about normal female sexuality is still based on the ideas of clinicians and writers at the end of the 19th to the middle of the 20th centuries,” wrote a psychologist from Sheffield. “Victorian and patriarchal ideas continue to inform research and popular opinion.” She and others think we should stop counting orgasms and reject historical assumptions about sex (such as heterosexuality and monogamy) if we are to make any meaningful progress. Some women were happy for their problems to be medicalised (because it meant they were finally taken seriously and treated), but other respondents, usually doctors, saw female sexual dysfunction as the latest in a long line of “diseases,” conveniently invented or expanded to fit an emerging treatment. The prevalence of “depression” went up sharply after the advent of antidepressants, the menopause became a disease when HRT arrived, and memory loss associated with ageing became “mild cognitive impairment” to allow treatment with anti-dementia drugs. The result, says one psychiatrist, of “uncritical medical thinking up against a pushy drugs industry.” “Profit driven medical research biases medical care toward treatments and strategies that make money for drug companies—all too often at the expense of women's health and lives” wrote a respondent from the National Women's Health Network in the United States. Another added: “Does this not lead to a simplification and impoverishment of what it means to be human?” One doctor criticised his profession for feebly accepting money and gifts from drug companies (then wringing their hands about being manipulated) in the same way that people eat burgers then blame McDonald's for making them fat. In general though, the issue of industry funding took second place to the more heated debate about the nature of women's sexuality. Only a dozen respondents even mentioned it. Four responses defended the drugs industry, or conceded that since decent research into sexual function was well overdue, industry funding was better than no funding at all. The real villains, said one sexual health specialist from Italy, are not drug companies but national health systems, including his own, that cannot or will not pay for independent research on human sexuality. 4-1. Moynihan R. The making of a disease: female sexual dysfunction. BMJ. 2003;326:45–47. . (4 January.). [PubMed]
Author's reply Ray Moynihan, journalist 1312 31st Street, NW, Washington, DC 20036, USA Email: raymond.moynihan/at/verizon.net Editor—The many email responses to and ongoing media coverage of my article on female sexual dysfunction bring a welcome public scrutiny to the role of pharmaceutical companies in shaping public attitudes towards health and illness. While also welcoming the letter from Pfizer's Dr Doogan, I respectfully reject his claims of “inaccuracies and false allegations” and suggest interested parties may like to reread the original article. Less welcome were secretive though ultimately clumsy corporate attempts to orchestrate a community backlash to the points of view of a range of researchers canvassed in the article. One such attempt was made by a public relations company sending confidential emails to women's groups around the world, including the Canadian Women's Health Network, seeking help to “counter” aspects of the BMJ piece on behalf of an unnamed pharmaceutical company. 5-1 Canadian journalists recently discovered that Pfizer was in fact the unnamed client. When questioned about their public relations company's secretive attempts to “counter” the article, a Pfizer spokesperson described the activities as “customary and unremarkable” and part of a plan to “establish appropriate platforms to increase patient awareness and recruit for study subjects.” As Barbara Marshall explains, the point of the article was “not to suggest that women's sexual problems are of no medical interest, or that women's suffering from them is immaterial.” 5-2 Instead, it was to offer reasons “to be cautious about uncritically embracing a disease-model which, like that for erectile dysfunction before it, is expanding to render an increasing number of difficulties as biomedical dysfunctions.” 5-2A recent study of widening disease definitions found 75% of the adult American population may now have at least one of four medical conditions, with half the population having a high cholesterol concentration. 5-3 It may well be time to reread Disease Mongers. 5-45-1. Moynihan R. Company launches campaign to “counter” BMJclaims. BMJ. 2003;326:120. . (18 January.). [PubMed] 5-3. Schwartz L, Woloshin S. Changing disease definitions: implications for disease prevalence. Effective Clin Pract. 1999;2:76–85. [PubMed] 5-4. Payer L. Disease-mongers: how doctors, drug companies and insurers are making you feel sick. Chichester: Wiley; 1992.
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