Importantly, since at least 1998 the conventional view among those who have been promoting a more medical approach to FSD has been that a woman must be distressed by her situation before she can qualify for a diagnosis.7 Yet the original survey questions made no mention of distress. As it turns out, the 1999 journal article actually carried a small but very significant caveat to its findings. It noted, almost in passing, that its results were ‘not equivalent to clinical diagnosis’ of dysfunction. Unfortunately, caveats like this have too often been lost in the gold rush to build this lucrative new condition.
Impressive statistics like 43 per cent can serve very important roles. Being able to throw around enormous estimates of the prevalence of a medical condition directly helps drug companies to claim there is a gaping ‘unmet need’ for their new products. It also helps researchers to attract the attention of funding bodies, and patient advocacy groups to generate interest from journalists keen for a dramatic headline. In short, these figures help bring the recognition each field of medicine so desperately seems to want—and specialists working in this new field of sexual medicine are no exception.8
One of the key textbooks about women’s sexual dysfunction actually makes a direct reference to the critical importance of the 43 per cent figure. On page 745 of Women’s Sexual Function and Dysfunction, the editors acknowledge concerns that such large figures may give the appearance that ordinary life experiences are being portrayed as the signs of a medical condition.9 Yet, according to the editors of this textbook, the survey that produced the 43 per cent statistic has proved very beneficial in ‘spreading the word’ about sexual dysfunction to those women who qualify for a clinical diagnosis. At the same time though, the inflated nature of the statistic has helped create a strong backlash. Leonore Tiefer, like many others in the field, rejects the claim that 43 per cent of women suffer with a dysfunction, and sees the figure as being extremely unhelpful. But she says with her trademark sense of humour that she finds the 760-page textbook very useful around the office, not least because its size is just right for doing upper body exercises!
Another of those concerned about the size of the 43 per cent figure has been psychologist Dr Sandra Leiblum. She has argued that genuine dysfunction among women is less common than 43 per cent, and that the statistic has contributed to an over-medicalisation of women’s sexual experiences. ‘I think there is dissatisfaction and perhaps disinterest among a lot of women, but that doesn’t mean they have a disease,’ she said in an interview in 2002.10 Dr Irwin Goldstein, one of the editors of Women’s Sexual Function and Dysfunction, has dismissed suggestions from his colleague that the 43 per cent may indicate the prevalence of difficulties rather than real dysfunction. ‘I love psychologists,’ he told a reporter, ‘but they don’t deal with evidence.’
Back in February 1999, it wasn’t long before Ed Laumann’s pleasure about his latest publication was turning into an experience more akin to pain. Just four days after publication, a major piece appeared in the New York Times. The Times was reporting that the Journal of the American Medical Association had failed to reveal that two authors of the 43 per cent article had some sort of financial relationship with the pharmaceutical giant Pfizer.11 One of those authors was Ed Laumann. As the Times pointed out, the journal article did find that many common sexual problems had social and emotional roots, which drugs couldn’t do much about. But the journal article had also called for the development of ‘appropriate therapies’ for the vast numbers of supposedly dysfunctional women. Those therapies could potentially include counselling and drugs—in particular Pfizer’s Viagra, which had just been approved for men and was at that time actively being studied in women. In other words, Pfizer stood to benefit greatly from the article’s findings of an enormous potential market among women—a great ‘unmet need’. Therefore, any connection between the article’s authors and the company represented the sort of conflict of interest that should have been disclosed, but hadn’t been.
Pfizer had not funded the original national survey, nor had it had anything to do with the later rewriting of results. However, Ed Laumann had joined one of Pfizer’s advisory committees in the lead-up to the launch of Viagra, and that fact was not disclosed in the article. The second author, whose conflicts of interest were similarly not disclosed, was Ray Rosen, the psychologist who’d organised that crucial meeting between drug companies and sex researchers at Cape Cod just a year or so earlier. Two months after the 43 per cent article first appeared, an embarrassing correction was published by the Journal of the American Medical Association. In tiny print, it was disclosed that Laumann had served on Pfizer’s committee, and that Rosen had worked as a consultant or received research support from a total of five drug companies, including Pfizer.12
According to Ed Laumann, the idea for the 1999 journal article focusing on the prevalence of sexual dysfunction in men and woman had come from Rosen in the first place. ‘Ray suggested it to me,’ Laumann said. He explained that Rosen used to quote the statistics from the earlier book of survey results, but that a short article in a big journal might be a better way of making people more widely aware of them. Dr Rosen declined to answer questions for this book, so it is unclear how he sees the background to the famous paper or the controversy and criticism surrounding the infamous 43 per cent figure. Ed Laumann, however, was happy to chat about both subjects, over morning tea at a big drug company-funded sex conference in Paris a decade later, in the exhibit hall just across the way from the Pfizer stand.
So what did the sociologist think about the way that 43 per cent statistic had been used to represent an estimate of the numbers of women with a medical dysfunction? ‘That’s clearly a misrepresentation,’ Laumann said with evident frustration. ‘First of all I don’t think that these things are medical dysfunctions, in the sense that they should require active intervention.’ And how did he feel about his figures being used as an indication of the size of the market of women who might need drugs? ‘The problem is you can’t really control how people are going to spin numbers,’ he responded, adding that it would be a mistake to see 43 per cent of women as a potential market for medicines: ‘It’s like dangling a huge carrot out there to say, just look at all those people, half the population, ready to gobble some kind of solution, medication or something like that. It’s a lack of understanding of what it is that really drives those numbers. And what drives the numbers is stress, physical and social stress, exhaustion, not being in a relationship with somebody you care about, so you’re not sexually interested.’13
The Chicago sociologist has clearly been stung by the heated controversy surrounding this work and the repeated criticism of the 43 per cent figure. In subsequent articles, he’s been careful to make his caveats more prominent. In a chapter in Women’s Sexual Function and Dysfunction, Ed Laumann and a colleague analysed the results of fifteen surveys designed to ascertain how many women have the condition. They came up with some scathing criticisms of their own about the way in which common difficulties uncovered during these surveys are often portrayed. ‘Despite widespread usage of the term “sexual dysfunction”,’ they wrote, ‘most of these studies rely not on clinical diagnosis of dysfunction, but on self-reports of symptoms or sexual problems.’14
Laumann went on to emphasise that in almost all the surveys carried out, the high rates of sexual problems apparently being uncovered did not equate to rates of medical dysfunction that might be diagnosed according to the technical definitions. One of the only studies to actually try to find out how many men and women in the population suffered from a diagnosable dysfunction came up with