The notion that both partners in a heterosexual relationship can consistently come to climax simply through intercourse will sound awfully old-fashioned to some readers. Certainly many women can and do reach orgasm through intercourse. But since Kinsey, and indeed even before, the early science of sexuality was confirming that, for many women, the clitoris was the site of their orgasm, and that vaginal intercourse alone was not routinely going to bring all women to climax. Yet so much popular culture seemingly hasn’t caught up with the facts. How many sex scenes in highly regarded films still replay an outdated version of love-making based primarily and solely on intercourse? Try to name a few Hollywood blockbusters, or even art-house features, that accurately portray the physical reality of female orgasm. Even in much supposedly sophisticated pornography, according to Hite, clitoral stimulation is used only as a warm-up, and is not portrayed to the point of climax. For her, the dominant form of sex—even in the twenty-first century—is one that still puts male orgasm before female orgasm, reflecting the still subservient position of women in society as a whole: ‘It’s not arousal pills we need, but a whole new kind of physical relations with each other.’
Exposing the uncertainty and debate around whether women’s common sexual problems are best classified as dysfunctions or difficulties is not an attempt to trivialise them. On the contrary, the hope is that doctors will diagnose women, and offer them therapies, only when they really require them, rather than because a powerful drug company that is funding their education wants to see tens of millions of women labelled in order to open the doors to a new mass market. Labelling a woman with a medical condition when she mightn’t actually have one can mean failing to get to the root of her problem—especially if it is not her problem alone but has arisen from her relationship. A wrong diagnosis and potentially unnecessary medications can carry harms and costs for the individual woman involved, as well as for those footing the bill for national health budgets, already straining under the weight of too much medicine.43
Much of the building of the science of this new dysfunction has happened in the light shining out from that 1997 meeting in Cape Cod, where Ray Rosen so successfully helped to bring together the doctors and the drug companies. Another big milestone was laid down less than two years later in 1999, when a landmark article appeared in one of the world’s leading medical journals. The article in the Journal of the American Medical Association reported on the results of a large sex survey.44 It stated baldly that 43 per cent of women suffered from some form of sexual dysfunction, and that this was an important public health concern. As we’ll soon discover, the big figure sparked an even bigger reaction. But here was the next building block in the foundation for the new disease that Darby Stephens and her colleagues and competitors in the industry were rushing to help develop.
[T]he total prevalence of sexual dysfunction . . . for women . . . 43% . . . an important public health concern.
—Journal of the American Medical Association, 1999
Let us be absolutely clear here. The article in the Journal of the American Medical Association that famously featured the 43 per cent figure1 gave birth to one of the most pervasive medical myths of our time. The claim flowing from the article—that there is a condition called ‘female sexual dysfunction’ requiring treatment and affecting one in every two women—is an exaggeration as extreme as it is absurd. The evidence assembled in the article never supported such an assertion, as even its lead author attests, yet different versions of this claim have been shouted far and wide ever since. Since its publication in 1999, the influential journal article has been cited by other scientific papers more than 1000 times, and in the wider culture on tens of thousands of occasions.2
‘Bad news in the bedroom, a sex study finds widespread sexual dysfunction’, screeched one popular magazine when the journal article first appeared.3 A management consultancy firm excitedly pointed out that, with 43 per cent of women suffering from this ‘treatable disease’, there must be an awful lot of ‘unmet need’, and the ‘sexual dysfunction market’ would offer great opportunities for companies that sell therapies.4 The 43 per cent figure worked its way from scientific journals into medical textbooks and magazine articles all over the world, becoming part of the scientific bedrock for this new disease. Yet no matter how many times the statistic is repeated, it doesn’t make the claim of a medical condition affecting one in every two women any more accurate or any less misleading. The way such figures can come to be so influential is a fascinating part of the story of how modern diseases are made, and FSD is the latest example we have. So where better to start this part of the tale than on a Wednesday in February 1999, the day this 43 per cent figure first emerged into the glare of global publicity.
Ed Laumann’s striking blue eyes shine out at you from his strong sincere face, fringed these days by his shining white hair. The professor of sociology from Chicago University has had a long research interest in human sexuality. He even holds the distinction of having had the US government try to shut down public funding for some of his work. A number of politicians were morally objecting to a large sex survey Laumann had wanted to run, back in the days when conservatives were still in the political ascendency in Washington. His sex survey eventually went ahead with funding from philanthropic foundations, and the results were published in a book in the early 1990s.5 Several years later, a selected portion of those survey results would be re-published in detail in the Journal of the American Medical Association, with Edward O. Laumann listed as first author.
The sociologist is particularly proud of the original survey, which was based on a large national sample of interviews with over 3000 Americans. It has, in fact, been highly praised as one of the first to use modern statistical methods of ‘probability sampling’. That’s the method used to try to gather a truly representative group of people in order to give a reliable picture of a whole nation’s sexuality. Alfred Kinsey’s famous interviews with more than 10 000 men and women, while historic, did not employ those same sampling methods, and his findings have been criticised for not being representative.
When the HIV epidemic hit in the 1980s, Kinsey’s work (despite its limitations) was still one of the most comprehensive surveys of American sexual behaviour. Clearly there was a desperate need to update the knowledge and learn more about the sexual behaviour of Americans, hence the motivation for Laumann’s survey. As it turned out, the study found lower rates of homosexuality than Kinsey did; unsurprisingly, it also discovered that a person’s chances of catching a sexually transmitted infection went up dramatically as the number of sexual partners increased.
While the main focus of the national sex study was about trying to better understand and fight HIV/AIDS, it included almost as a sideline some questions about sexual difficulties. Among many other items in the hour-and-a-half-long survey interview, the staff working with Ed Laumann asked women a quick series of simple questions about whether they’d experienced any of seven common difficulties for several months or more during the past year. The questions asked things like whether they’d lacked interest in sex, felt anxious about their sexual performance, had trouble with lubrication, failed to orgasm, came to orgasm too quickly or experienced pain on intercourse. By simply answering yes to just one of these questions, women were then categorised as having a sexual dysfunction. When they were all added up, the number of women in this category reached 43 per cent. And this is the source of the 43 per cent statistic that appeared in the aforementioned article, which has become part of the foundation for a global campaign claiming almost half of all women suffer with a sexual dysfunction that might be treatable with powerful drugs.
The obvious problem is that common difficulties are being confused