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Why Viagra for women still doesn't exist

By Sarah Hosseini

In 2009, Amanda Parrish started her clinical trial for the Addyi, the drug dubbed the first “female Viagra.” She took one pink pill per night and was told she might feel “something” in 30 to 60 days. Parrish, then 46, felt tingles in two weeks. Instead of making up excuses to avoid sex with her partner, she found herself texting him in the middle of the day with messages like, Do you want to have ME for lunch? The drug seemed to be the magic solution to her sexual frustrations.

Prior to taking Addyi, Parrish had been diagnosed with Hypoactive Sexual Desire Disorder or HSDD, a condition characterized by the lack of sexual desire not caused by mental health issues, problems in a relationship, or by another medication. HSDD can happen at any age, though starting at 40, women's ovaries make less estrogen, which can also contribute to dwindling sex drive. Currently, Addyi is only for pre-menopausal women. “It was just like a light switch, and it switched back on,” she says about starting Addyi. But after six months of taking the drug, generically known as flibanserin, Parrish got a call from Sprout Pharmaceuticals telling her to return her pills. The FDA had reportedly shot down the drug for the third time due to only modest results in sexual drive and side effects like dizziness, nausea, fainting, and drowsiness (though the med was later approved in 2015).

In the years that followed, the drug, whose entrance on the market was expected to make a splash comparable to male Viagra, fizzled out like an old flame. Some speculate that part of the reason for that is the med’s alcohol warning, which cautions women not to drink while taking it. Another issue is the cost: Addyi is supposed to carry a $20 to $30 copay for patients with commercial health insurance coverage, but that’s only if your health insurance company covers the drug — some companies do not. Otherwise, it can cost $426 for a 30-day supply of pills, though coupon and discount options are available on the Addyi website. Even with those challenges, Addyi was the only drug option for enhancing women’s sexual health for four years, until very recently.

In September, a new “female Viagra” will hit the U.S. market called Vyleesi, or bremelanotide. Like Viagra, women can use the drug on demand for sex, though it’s not a pill. The patient injects themselves with the drug in the abdomen or thigh 45 minutes before anticipated sex. However, calling Vyleesi “female Viagra,” in any sense is actually a bit of a misnomer. Actual Viagra works on the genitals and increases blood flow to the penis causing an erection. Vyleesi and Addyi aren’t genitalia-focused; they’re brain-focused, aiming to increase desire and libido in pre-menopausal women. Vyleesi theoretically works by binding to melanocortin receptors in the central nervous system, but just like Addyi, the exact mechanism of the drug is unknown. No long-term studies have been done so far on Vyleesi. The FDA approved it this June (the FDA can approve drugs based off of initial clinical trial results — without long-term studies or several phases of clinical trials), and the cost of Vyleesi is still not clear. It is likely again, contingent upon a person’s insurance coverage. When contacted for comment, a spokesperson for the company that made the drug, AMAG Pharmaceuticals, said women will initially be able to access their first four-pack of the auto-injectors for free and subsequent refills will be $99 while they work with insurance companies to broaden coverage.

Since male Viagra came on the scene almost 20 years ago, the jackrabbit race to close the so-called “pleasure gap” between men and women has intensified, though anticlimactically. There aren’t clear reasons, but some will say women’s sexual responses are still largely misunderstood. Additionally, women’s health issues (including sexual health) are notoriously ignored by the medical community. And perhaps culturally the perception is that men are entitled to having all the boners they want, on their terms, and women are just expected to keep up.

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Right now, men have approximately seven pharmaceutical treatment options available right now for sexual dysfunctions, and women have two. Simmering underneath this passionate journey to create a “female Viagra” equivalent seems to be a collective obsessive anxiety about sex in our culture: We fret about the frequency in which we’re having (or not having) it, how thrilling it is or isn’t, and how it’s supposed to look, feel, and at times, how it’s supposed to be performed. Perhaps our fear is the driving force behind the drugs. Are women measuring up to the standard? What is the standard? The medicalization of sexuality appears to be a convenient answer.

Despite the hasty approval of Vyleesi and unknowns that still surround it, many in the healthcare field dedicated to women’s sexual health are celebrating this step. “Women need options and I am so thrilled that they have two now. We need more,” says Dr. Rachel Rubin, a Washington, D.C.-based urologist and sexual medicine specialist who’s passionate about closing the pleasure gap between men and women.

She does, however, worry about the logistics of administering the drug. “People are excited about Vyleesi, but it’s an injection,” she says. Anyone who hates needles or doesn’t love the idea of jump starting their sex drive with a painful experience can see how it could be a tough sell for women. And the shot aspect may not be the only turn off. Side effects of the drug include nausea, headache, and hyperpigmentation of the face, gums, and breasts.

Additionally, there’s concern about the thin data. Most women in the Vyleesi trial didn’t use the drug more than two or three times a month, and no more than once a week. Long-term side effects remain unknown. (Vyleesi was contacted for comment, but didn’t respond with this specific information at the time of publication). Rubin agrees that women’s sexual health is notoriously understudied and underfunded but adds, “Women are smart enough to research their options and decide which side effects they’re willing to endure to try a drug that may help them.” While that’s true, it seems that information on men’s Viagra is much more readily available thanks to magnanimous marketing campaigns, whereas Vyleesi literally says “psst!” on the home page like it’s some kind of secret.

Then there are the seemingly lackluster results of Vyleesi in the clinical trial. Only about 25 percent of patients treated with Vyleesi had an increase in their sexual desire score, compared to about 17 percent of those who took a placebo. Still, experts feel that it’s a start. “Women with HSDD or low desire have sex on average 2.5 times per month. That includes duty sex and mercy sex,” Rubin says, referring to times when your partner wants sex but you’re not as into it. “On these drugs women may not have had more sex necessarily — it was just more pleasurable. When you tell a woman that you can make one of those duty sex [experiences] more pleasurable, you will change her relationship, her feelings of self-worth, and her confidence.”

Remembering my own anxiety surrounding “duty sex” while six weeks postpartum and the crushing expectation of it (while taking care of a newborn and healing from a C-section), I ask her about the emotional implications of duty or mercy sex. I had always thought both fell into the dangerous grey area between being a “good” partner and sexual coercion. “Communication with your partner is so important. It’s not our place to ask women why they have sex,” she says. “What is important about sex is pleasure, pleasure, pleasure.”

Viagra is much more readily available thanks to magnanimous marketing campaigns, whereas Vyleesi literally says “psst!” on the home page like it’s some kind of secret.

Addressing sexual dysfunction or difficulties for both men and women are relatively new concepts. Related research first appeared in medical literature in 1952 in the Diagnostic and Statistical Manual of Mental Disorders (DSM) which sets the standards for mental health and mental disorders throughout the world. In the book, Sex Is Not a Natural Act & Other Essays by educator, researcher, and sex therapist Leonore Tiefer, it’s evident how the nomenclature for sexual disorders and sexual dysfunctions has evolved over the decades; sexual difficulties were originally considered only symptoms of psychiatric disorders, not the actual illness.

In 1968, the DSM listed sexual problems relating to performance of heterosexual intercourse (no other sexual acts are mentioned, nor is masturbation) and instead of these sexual issues being symptoms, they are considered psychiatric disorders which express themselves through physical dysfunction. This means a person could be diagnosed with a full-blown sexual disorder if they didn’t get pleasure from coitus, effectively upholding heteronormative models of sex and pleasure as the gold standard.

In her book, Tiefer observes that the list and descriptions of sexual dysfunctions occupy six entire pages in the DSM and this is when we first see HSDD, or Hypoactive Sexual Desire Disorder, for which both Addyi and Vyleesi claim to treat. It’s estimated that one third of adult women in the US manage HSDD, though the high number makes some critics suspicious. If HSDD is that ubiquitous, it’s possible that periods of low desire are not a “dysfunction,” but rather a normal part of human sexuality.

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So can the solution to a society’s problems with sex, both male and female, be solved by a pill?

If it’s a matter of function only, perhaps. But solely considering a chemical solution completely discounts how complex sexuality is and the social context in which male and female sexuality is constructed. Non-biological influences such as gendered power imbalance in the bedroom, sexual violence in our culture statistically effecting women at high rates, and the glaring lack of sex education in our country are just some of the social influences critics of these drugs would like healthcare providers to consider.

Cyndi Darnell is a New York City-based sex therapist and educator who believes this preoccupation with making Viagra-like drugs for women is really about making money. “The quest for female Viagra is a misnomer and completely ignores the research on what provides erotic incentive for women,” Darnell says. Creating an environment where pleasure and wellbeing are centered for women (and for men too), will drive sexual incentive. She believes women may want more sex if they were having better sex, which, to her, is the real problem. “There is not and never will be a pill for bad sex, selfish lovers, and a culture that is profoundly uncomfortable with women in control of their erotic freedom,” she says. “Until we change the context in which women experience erotic pleasure on their terms, it's up to individuals and their partners to create situations that allow pleasure to flourish and thrive.”

Parrish, now 56, no longer takes Addyi, though she’s still arguably the most visible and vocal supporter of the drug. Just searching her name and “Viagra” yielded over 50,000 results. When I tell her I couldn’t get one woman to agree to talk to me about their experiences with Addyi, she wasn’t surprised. “There were approximately 10,000 women in that study and no one was willing to speak publicly about it, except me,” she says. I wonder if these women in the trial are ashamed to talk about sex in general — or embarrased about not wanting it, or wanting more of it.

Through talking about women’s sexual issues, treatment options, and the safety and effectiveness of them, I pause and realize something: We’re talking about women and sex. And women having sexual freedom. In a country where we’re still debating the rights of women having agency over their own bodies, this concept of sexual freedom is still largely taboo. Whether the drugs work or not, should exist or shouldn’t, these drugs are the catalyst for important conversations to come. Perhaps the sex we’re having is dysfunctional and the antidote is a culture-wide fix. Such a pill might be hard to swallow.