Sex, Lies, and Pharmaceuticals. Ray Moynihan

of the science of this new dysfunction. Most immediately it would lead to more meetings of sex researchers, many of which would be heavily sponsored by industry. The following year, a group of ‘thought leaders’, including Ray Rosen, would meet in Boston in a closed session to revise the definitions of female sexual dysfunction, or FSD. The vast majority of the nineteen ‘thought leaders’ would disclose that they had some sort of relationship with industry.³¹ As in many areas of medicine, the drug companies weren’t writing the definitions, but the panels of experts who did included many with financial ties to those companies. Typically, those ties could involve being an adviser or consultant, being contracted to do research or being paid for speaking engagements.

      That important meeting, at which the definitions were revised, took place just up the road from Cape Cod in Boston, where another of Ray Rosen’s colleagues, Dr Irwin Goldstein, was based. A professor of urology and gynaecology, Irwin Goldstein started his professional life as an engineer before switching to sex research, an area in which he is highly regarded and has become well recognised. A practising doctor and widely published university academic, Goldstein has also retained his boyish good looks along the way. In addition to all his publicly funded research via grants from the National Institutes of Health, Goldstein has worked with many of the world’s biggest drug companies, which he sees as playing a paramount role in helping build the new science of sexual medicine.³²

      By the start of the twenty-first century, the gatherings of this group of researchers interested in women’s sexual difficulties were becoming annual scientific conferences, now attracting support from more than twenty companies, with Pfizer as a key sponsor.³³ And the drug companies weren’t just funding the get-togethers: on some occasions, their staff were actually attending as well, taking part inside the scientific sessions. These were the sorts of activities to which drug company research manager Darby Stephens was referring when she talked of working closely with ‘thought leaders’ to jointly develop this new disease entity. Yet while this close working relationship is the norm in medicine, not all drug company managers are as candid when it comes to describing it.³⁴ An official from Pfizer was far less forthcoming than Darby Stephens when he was interviewed about his company’s activities. The way he told it, the giant corporation was simply playing a ‘passive’ role by providing unrestricted grants for conferences in response to requests from physicians. Importantly, he also referred to FSD as a ‘disease’.³⁵

      More recently, Pfizer has described the grants it provides for conferences as part of a much broader process of partnering with medical, scientific and patient organisations, helping to ‘strengthen communities’ and produce a ‘healthier world’. Confirming Irwin Goldstein’s views about industry’s paramount role, the world’s biggest drug giant proudly states that it has conducted and sponsored many scientific studies in the field of FSD, not just testing drugs, but also generating knowledge about the ‘nature of female sexual dysfunction and its impact on women and their partners’.³⁶

      The sponsored gatherings at Cape Cod and Boston weren’t only a chance for informal socialising and an opportunity to build friendships between marketing managers and university-based researchers. They were also the places where the new science of sexual medicine was being constructed, the new corporate-sponsored knowledge was being created, and the latest definitions of FSD were being written. These gatherings can be highly influential in the wider world of medicine and among the general public. Deliberations at these meetings are often covered in the media, and later published as important journal articles or guidelines for treatment, which in turn can be carried dutifully to your doctor’s door by friendly drug company sales reps eager to educate the medical profession about the latest disorders. Embedded in a lot of this material is a strong view that common sexual difficulties are best described as medical dysfunctions. The downstream impact of all this on your doctor and the way he or she thinks about the problems in your sex life cannot be overstated.

      Within a few short years of the historic meeting in Cape Cod, the drug companies were funding far more than just conferences for sex specialists. They would hand out direct grants to universities to educate medical students about women’s sexual health, fund educational seminars for practising doctors and workshops for healthcare journalists. In the case of Pfizer at least, some of their sales staff would also ply doctors with kickbacks and inducements, according to court documents from an official whistleblower.³⁷ All of this was long before any sex drug had even been approved for women. A key aim was to win widespread acceptance of the idea that a woman’s common sexual difficulties might be the sign of a treatable dysfunction. For many researchers, all this activity was bringing what they regarded as long-overdue recognition to women’s sexual suffering, and legitimacy to its study. For the drug companies, it was a strategic part of the planning for what was being billed as the next billion-dollar market.

      A forward-looking business intelligence report in 2003 named FSD drugs as an area of great future growth for the pharmaceutical industry, part of the burgeoning ‘lifestyle’ market including medicines for baldness, smoking cessation and obesity.³⁸ The report was prepared for industry insiders and, with a hefty price tag, was never intended for public consumption. However, a leaked copy described how drug companies were ‘expanding the patient pool’ by using marketing campaigns to change public perceptions about things that used to be considered part of normal life. ‘The medicalisation of many natural processes,’ the report observed, ‘is creating markets for lifestyle drugs for those who want to optimise quality of life.’ It predicted that the market for FSD drugs could soon approach a billion dollars a year. The days when the treatment of sex problems was dominated by the idea that therapy could render sexual inadequacy obsolete were quickly forgotten, swept away in a collective enthusiasm for new panaceas to treat this new dysfunction, and the billions that might flow from it. But the enthusiasm was not universal.

      Leonore Tiefer was by now pointing out in her writings that the post-sixties opportunities for the sexual emancipation of women were sadly being squandered in the medical takeover of sex.³⁹ Rather than attaining further freedom, the fear was that women were being subtly encouraged to feel inadequate, or even dysfunctional, if they failed to live up to a new unrealistic norm of a constant desire for sex. Right on cue, the new blue pill bounced straight from the doctor’s surgery to the centre of popular culture. Viagra famously made a cameo appearance in the television series Sex and the City, when Samantha took the drug and apparently enhanced her already considerable sexual enthusiasm.⁴⁰ Apart from her broader social critique, Tiefer was also busy documenting drug company sponsorship of all the important meetings where the new disorders were being developed. The resulting evidence offered a rare insight into the extraordinary extent of pharmaceutical involvement with an emerging field of medicine.

      Informed in part by this evidence, an article in the British Medical Journal (BMJ) described the making of FSD as the ‘freshest, clearest example we have’ of the corporate-sponsored creation of a disease.⁴¹ The article caused media reaction around the world, and was heavily criticised by several ‘thought leaders’ in sex research. They felt it played down the genuine suffering of women with legitimate sexual difficulties and set back the aim of finding safe and effective treatments for them.

      The BMJ piece also brought a negative response from Shere Hite, author of The Hite Report. She criticised it, but from a very different perspective. For her, it didn’t go anywhere near far enough. Hite claimed that in the race to get a pill to market, the pharmaceutical industry was fundamentally misunderstanding women’s sexuality due to serious flaws in the definitions being used. She argued that the four supposedly distinct disorders of FSD—desire, arousal, orgasm and pain—were in reality not independent of each other. ‘Anticipating pain will kill off desire,’ she wrote in a feisty opinion piece published internationally.⁴² ‘An arousal pill may be a costly waste of time if the root cause of that lack of arousal is not addressed.’

      Hite’s perspective, based on the material collected for her research, is that many difficulties aren’t due to a dysfunction, but rather to the century-old misunderstanding of female sexual pleasure, dating back at least to Freud. A lack of orgasm during intercourse is a ‘crucial and common underlying reason why many women become disenchanted and uninterested in sex’, she argued,