The Science of Passion
Denise’s husband thought she was having an affair. The couple’s love life had gone down the tubes--to the point, says 33-year-old Denise, that she didn’t want to be touched and would even orchestrate a passion-damping fight with her husband if she sensed sex was in the cards that night.
“It was a big, huge strain on my marriage,” she says.
Fifty-three-year-old Randee’s love life was also troubled. She even caught her husband putting Xs on the calendar one day--and he sheepishly admitted that he was marking down the rare times they made love.
“It’s frustrating,” she says. “I always had an enjoyable sex life--I used to have multiple orgasms all the time. But that has gone downhill to the point where I don’t even think about it. I don’t have discomfort during intercourse. I just don’t have any interest.”
Both Denise, who lives near Boston, and Randee, from Bakersfield, are among the estimated 43% of American women who have problems with their sex lives--and both have turned to medicine to help rekindle the passion.
In both Randee’s and Denise’s cases, surgery caused sudden sea changes in their sexuality. For Denise, an uncomplicated search for polyps in her uterus turned serious when doctors accidentally cut an artery and some nerves, depriving her genitals of normal feeling and blood flow. For Randee, a 1980 operation took away her uterus and ovaries, robbing her of hormones that now appear to be intimately tied to a woman’s sex drive.
Women without such complicated medical histories--many of whom have entered menopause, and some even younger than that--are also turning to medical remedies. Still more stand to do so in the future, as drug companies plug away at researching new libido- and arousal-enhancing medicines for women and as doctors pay more attention to such issues.
Enthusiasm may rise or fall later this month with the release of results from the first controlled trial measuring the effects on women of the male erection-enhancement drug Viagra.
Some sex researchers welcome this new era, which resulted in large part from Viagra’s success in men: At last, they say, science is getting serious about a long-neglected area of women’s health and well-being. Others recoil at what they see as an inappropriate medicalization of a very personal part of women’s lives--one, they say, that has much more to do with education about sexual technique and dealing with the stresses of life and marriage than fixing any biological problem.
But given the attention generated by male arousal boosters--first implants, then injectable drugs to help achieve erections, and now Viagra and the development of still more arousal-inducing medicines--experts are not surprised that women are getting attention, even though the focus is still much more on men.
“It was inevitable that it would come around to women,” says Leonore Tiefer, a New York clinical psychologist and sexologist who strongly opposes this new focus. “I think there’s going to be a tremendous amount of harm done to people.” Sex researchers, she says, have amassed a huge amount of information about the emotional and societal causes of sexual problems, “but there has been just a pea-sized interest in those warehouses of data.”
Others feel that a medical approach is perfectly legitimate. We are, after all, biological beings, chockablock with nerves and chemicals. Sometimes things go wrong with nerves and chemicals, hence the sexual problems some people have when they take blood-pressure drugs or antidepressants. And today doctors understand--as they didn’t in the past--that erection problems in men are often rooted in biology.
Female sexual biology, they say, has long been neglected.
“Medical books have chapters and chapters dedicated to male sexual anatomy and physiology and minute amounts addressing female sexual anatomy,” says Laura Berman, co-director and sex therapist for the Women’s Sexual Health Center at Boston University Medical Center. “I feel it’s doing a disservice to women to look only at the emotional and relational part of sexuality.”
Whatever scientists discover about the physical side, plenty of people will be interested. It’s been years since the hackneyed word “frigid” sounded anything other than offensive and old-fashioned, but that doesn’t remove sex as a problem for many women at some time or other. We know this from advice columns, from confidences with friends, and from browsing magazines in the grocery store with their countless articles on how to bring “sizzle” back to the bedroom.
A large survey, published last year in the Journal of the American Medical Assn., showed that as many as 43% of women (and 31% of men) ages 18 to 59 reported some sexual difficulty within the previous 12 months. And while JAMA was criticized for not revealing that some of the report’s authors had received funding from companies such as Pfizer Inc., which makes Viagra, the stats were not in question. They mirror findings from earlier, smaller studies, and those of sexology pioneers Alfred Kinsey and William Masters and Virginia Johnson.
But the numbers don’t mean that 43% of American women need treatment for a sex problem, experts say.
“Some may report low arousal and that may be fine with them,” says Beth Meyerowitz, a USC psychologist and sex therapist. There’s no rule about how often couples have to have sex, after all.
Understanding the Science
Nor do the numbers explain what might be causing such complaints, though the fact that they are more common among women with emotional and health problems suggests that travails of life, such as depression, play significant roles.
But so too may biology.
Studying sexual biology in women is not as straightforward as it is in men, where scientists can monitor enlargement of penises. But there are plenty of changes taking place during arousal in a woman, some revealed by remarkable movies filmed from inside the vagina.
As a woman becomes aroused, muscles in the vagina relax, increasing its capacity. Blood vessels in the labia, clitoris and vagina dilate, just as they do in the penis, causing blood to rush into the genital area. As the blood supply builds up, plasma squeezes through holes in the walls of tiny capillaries, lubricating the vagina.
Scientists have built a bank of ingenious machines that can monitor these changes, including a tampon-like device that measures changes in vaginal blood supply. Since blood flow to the genitals is important for arousal in both men and women, and since Viagra enhances blood flow to the genitals, testing the pill on women was an obvious next step.
Denise took part in such a survey after visiting the offices of sex therapist Laura Berman and her sister and co-worker, urologist Jennifer Berman. After a battery of tests, she took the pills home. The very first time she and her husband used them, she says, “I had my first orgasm in two years--it was great!”
But Denise’s orgasms are often elusive. And the drug is expensive: Because Viagra isn’t yet approved for women by the U.S. Food and Drug Administration, her insurance won’t cover it. She and her husband pay out of pocket.
Despite testimonials from individuals like Denise, it isn’t yet clear how well Viagra works for women at large. There is a large placebo effect in any trial for sex remedies--an improvement that comes from simply thinking one has taken an effective drug. Results from small, uncontrolled studies performed on Viagra to date have been mixed, and some of them disappointing. Everyone is waiting for this month’s results of the first, controlled trial, on several hundred European women.
For a while, Denise was taking another pill--one that supplied the male hormone testosterone. If she could only take it again, she says, “things would be excellent.”
Testosterone isn’t just made by men. Women produce it too, both in their adrenal glands and their ovaries. And just as levels of estrogen start to fall as women approach menopause, leading to problems such as vaginal dryness that make intercourse less comfortable, levels of testosterone--which doctors can measure in patients’ blood--fall too. This loss, studies show, can cause sexual desire to dwindle.
Desire--the urge to even want sex in the first place--fell precipitously for Randee, who lost a large supply of her body’s testosterone when her ovaries were taken out.
No one knows what proportion of women with low desire have low testosterone (some scientists think that the number could be large), but it’s most likely in women like Randee and those who are approaching or have gone through menopause, says Dr. Glenn Braunstein, chairman of medicine at Cedars-Sinai Medical Center. (Ironically, he says, estrogen therapy may exacerbate the problem further, because it can cause changes that interfere with the action of testosterone.)
Testosterone supplements (such as the pill Estratest, which supplies both estrogen and testosterone) seem to help.
“Our studies and a number of others show that giving testosterone to women who are either naturally post-menopausal or who’ve had their ovaries removed increases libido, sexual pleasure, the initiation of sexual activity and also general well-being,” he says.
Does that mean that everyone who reaches menopause, or everyone who has low libido should automatically get a testosterone supplement? Not at all, say researchers. Testosterone may be of no use at all if blood tests show that a woman is making normal amounts. And testosterone has its distinct downside: Too much can cause acne and hairiness and can raise a person’s risk of heart disease (that’s why Denise had to stop taking it). When the hormone is taken orally, it travels first to the liver and can potentially damage that organ.
Thus, drug companies and scientists like Braunstein are experimenting with other approaches, such as creams or patches, or the development of testosterone drugs that augment desire without the medical downsides.
Randee, for instance, is a patient in a testosterone patch trial led by Braunstein. She’ll place the patch on her belly and replace it periodically. As the trial rolls on, she’ll fill out questionnaires about her sexual experiences and feelings--details, ironically, that she must not share with even her husband, who is excited and full of hope, she says, that the treatment will help patch up their sex life. No one will know until the end of the trial whether she’s receiving the hormone or a placebo.
Alternatives to Drugs
Some sex therapists balk at all this.
Drugs, they say, carry risks: Viagra, for instance, has been linked to heart attacks in some men. And, they ask, why go the medical route when there is an abundance of data--Tiefer’s “warehouses of data”--showing that the root of most women’s sexual problems lies not with biology but with their lives, and that sex therapy does a pretty good job of helping them?
The very term used for problems--”female sexual dysfunction”--raises a red flag for Carol Ellison, an Oakland-based psychologist who specializes in issues of sexuality and intimacy.
“I find it a terrible way of thinking about our sexuality,” she says.
And Mark Schwartz, director of the Masters and Johnson clinic in St. Louis, worries that pills for women will backfire on relationships, by causing women to ignore marital issues as well as their feelings and those of their partners. He’s seen that happen with Viagra sometimes when men take it.
“The man will get this erection, and the woman feels obligated to have sex with him . . . and it’s not very interesting or desirable for either of them,” he says.
But those who defend a biological approach say they’re not advocating pills and nothing but. They also ask--while conceding that such studies aren’t easy to do--whether sex therapy has been put to a rigorous scientific test.
“For years, sex therapy has been going on in this country, yet the amount of . . . data supporting how wonderful it is is few and far between,” says Dr. Irwin Goldstein, professor of urology at Boston University Medical Center.
Some sexual problems are well-treated by sex therapy, report Cindy Meston, clinical psychologist at the University of Texas at Austin, and Julia Heiman, professor of psychiatry and behavioral sciences at the University of Washington in Seattle, who reviewed such studies a few years back. Treatment for failure to reach orgasm, for instance--through a combination of education and masturbation exercises--has a high success rate.
But despite some favorable clinical reports, there are no well-designed trials for sex therapy’s impact on either problems of libido or problems of sexual arousal. And libido, agree sex therapists, is both the most common and most difficult of all sexual problems to treat.
As drug companies continue to work on new arousal- and libido-enhancing drugs, what many experts hope for at the end of the day is balance--that professionals dealing with sexual problems in patients will find the right place for therapy and medications. And thus woman will have more choices.
Denise and her husband have experienced both therapy and pill. From the drug, she says, she got back some basic, biological responses that have helped the couple enjoy a richer sex life. From therapy, she learned to retool her expectations and attitudes toward what sex was supposed to be about. That she shouldn’t apologize when she didn’t have an orgasm. That they didn’t need her to have an orgasm to have fun.
“They both helped together,” she says.
