It’s been a while since I’ve written about medicalisation. Which seems as good an excuse as any to revisit this issue and reflect on some of the developments in this area in healthcare, therapy and media.

A few months ago I took part in the 41st Maudsley Debate entitled ‘Love is a Drug’. Ben Goldacre and I spoke for the motion, Sandy Goldbeck-Wood and John Dean against it.

In fairness the title of the debate ‘This house believes that female sexual arousal disorder is a fabrication’ was somewhat misleading since it could be construed as saying there was no such thing as women having problems with desire and arousal. Obviously that’s a ridiculous idea for anyone to support, so Ben and I kept our focus more on the way female sexual problems have been medicalised, and what implications this can have (particularly in healthcare).

You can hear the debate and subsequent discussion here. Ben and I won the debate, although the discussion certainly indicated this is a complex area and one that is not always fully understood in terms of gender, politics and ‘bad science’. I think Ben’s points about teaching medical students (and healthcare staff more widely) to read and think critically about pharmaceutical research is important – particularly in relation to the area of sexual functioning which is heavily medicalised but often not taken seriously. Because it’s about sex.

Additional reviews of this debate can be found here, here and here.

This event follows a debate last year hosted by the British Medical Association which was also attended by John and Sandy, who discussed issues around female sexual dysfunction with Ray Moynihan (author of Sex, Lies and Pharmaceuticals) and Iona Heath.

Both of these discussions were focused towards a medical audience (with the Maudsley debate particularly aimed at medical students and trainee psychiatrists, and the BMA event at practising clinicians and therapists). While the Maudsley debate was open to the public the BMA event was invitation only, so there is a remaining problem of making discussions around medicalisation open to a wider audience.

One way this is being achieved is through screenings of Liz Canner’s amazing documentary ‘Orgasm Inc’ which have been taking place across the US, Canada and UK. Media coverage of this movie has also helped raise the profile of female sexual problems (examples here, here, here and here). Although unfortunately not all journalists covering this area ‘get’ all the issues surrounding this topic, particularly around medicalisation, evidence based practice, and endorsing largely untrialled/untested interventions).

This leaves us with some stubborn problems which still need tackling. These include:

Critiquing FSD = women don’t have problems
One of the most frustrating aspects of challenging the medicalisation of female sexual problems is the inevitable response from some journalists, medics, researchers and members of the public who interpret what you are actually saying as – ‘women don’t have sexual problems’. Clearly women who are experiencing sexual difficulties don’t want to be told they’re inventing their problems, and do want a solution. Those who are challenging medicalisation of sexual function are not saying women don’t have problems. They’re not saying sex isn’t important. What they are saying is that there are many reasons women experience problems, and an equal number of possible solutions to them (see here for more on this). And that it are the many causes and solutions that require exploring rather than assuming a woman who isn’t desiring sex is ill and requires a clinical solution (we unpack this to some degree in the Maudsley debate podcast linked above).

Discussing women’s problems = denying men have problems
Another real problem around talking about this topic is the focus on women. The media ignored the medicalisation of sex for a long while. Then did a lot to write and broadcast in ways that promoted pharmaceutical company agendas. Some media outlets have more recently decided to focus on the medicalisation problem, but generally in terms of focusing on women. This can partly be attributed to activism in this area, and partly due to rehearsing comfortable stereotypes – that women are not particularly sexual or are more likely to have problems with sex. This has led to criticisms that men’s sexual functioning has been ignored, or is not an issue. In terms of research that’s not really true. The challenging of medicalisation of male sexuality came before campaigns against the medicalisation of female sexual functioning. You can read some examples of that work here, here and here (It’s an area I’ve also researched and published on, as well as given advice to men about e.g. here and here).

What may be a more accurate statement is there is concern over men’s sexual functioning and the medicalisation of men’s sexual lives, but a lack of interest in the mainstream media in really taking this up. Other activist and sceptic groups you’d expect to challenge this problem seem reluctant. Witness the general apathy to helping men affected by the actions of the Advanced Medical Institute as a prime example. It is difficult to get journalists to focus on this in terms of medicalisation of sexual functioning per se, rather than simply seeing it as a ‘woman’s issue’.

Media lack of awareness of/complicity in this area
One of the main issues in this area is the media often doesn’t ‘get’ medicalisation. Indeed promises of wonder drugs that will boost our sex lives attract editors like moths to flames. The result has been uncritical pickup of pharmaceutical research on psychosexual problems, either promoting products that aren’t all that effective, or showcasing drugs that aren’t even available for public use. Even where drugs for desire problems have been identified as ineffective media coverage continues to write about them as if they are – for example with media’s ongoing obsession with testosterone therapy as a sex drive booster for women. This parallels problems within medicine where practitioners simply don’t understand the influence of Big Pharma in this area, can’t access (or understand) the diverse literature about medicalisation and critical sexology, and remain unable to identify and appraise literature on this topic.

Where to next?
The problem of medicalisation and poor media coverage of sexual problems is not going away. So encouraging and recognising good quality reporting in this area is vital. Supporting screenings and discussions of documentaries like Orgasm Inc can help, as can more public events tackling this topic. Moving away from a debate style format (i.e. do problems exist or not) would also allow for perhaps a more nuanced discussion on medicalisation, how it happens, and how to recognise and respond to it. Focusing on this as an issue affecting cis and trans women and men, as well as different sexualities is important. As is reflecting on how we view psychosexual issues for different age groups (and what age groups, genders, sexualities do we seem most keen to pathologize). Helping medics, therapists, journalists and the public to understand core issues around medicalisation as well as critiquing research on treatments in this area would also be useful. As would challenging any suggestion that critiquing medicalisation equals denying people have psychosexual problems.

You may also be interested in responding to the classifications of psychosexual issues in the revised DSM (deadline 15 June), or learning more about the Medicalisation of Sex from this recent conference in Vancouver.

You may remember my previous post on the revisions being made to the DSM (Diagnostic and Statistical Manual of Mental Disorders). Over the past few years the existing DSM (IV) has been revised and the public invited to consult on its content. The DSM covers a range of mental health issues, which other bloggers and activists have been reflecting on. For the purpose of this blog I’ve focused on how the DSM will be approaching psychosexual issues – although it is worth noting concerns have been raised about how gender will also be approached (particularly around transgender issues).

The provisional DSM-V is now available for public comment, you have until June 15 to read, critique, question and add your views. Information about how to do this can be found via the DSM-V website .

To help us reflect on the psychosexual aspects of the provisional DSM-V I’ll draw your attention to the thoughts of the indomitable Leonore Tiefer who has shared these thoughts:

7) When you write to the DSM-V, don’t go on and on (the way I have here!!), but pick one point and make a strong argument. Maybe 200 words. Pick a dysfunction that you feel strongly about E.g., are you glad to see the disappearance of vaginismus and dyspareunia in favor of Genito-pelvic pain/penetration disorder? Do you think the changes in the orgasm category encourage hypervigilance? Do you think combining arousal and desire makes sense? Do you like the new modifiers/qualifiers or do you think they are window-dressing? Have they left anything out you wish were there (e.g., Male romance disorder)? etc.”

Tiefer makes some important points here about how psychosexual disorder is being characterised within the proposed DSM-V but you may also have your own thoughts about the way sex/relationships/intimacy is being constructed/pathologised when you read through the DSM-V draft.

Do please add your thoughts, send in your observations and particularly record any concerns that you have. It’s important we all try and do this if we are worried about medicalisation, commercialisation and sex. Many of the discussions on this topic have focused on female sexual functioning/medicalisation, but it’s important to note the DSM-V is also focusing on how male sexual problems are viewed, so focus your critiques here also. This is particularly important given how often male psychosexual issues and the manipulation of male anxieties around premature ejaculation and erectile dysfunction are ignored.

If you’re a journalist you may also want to use the pointers above to think critically about the provisional DSM-V, or more widely about how we conceptualise sex, gender and relationships.

Remember you’ve until June 15 to do this so get lobbying, write about this on blogs, share on twitter and where possible within the mainstream media and healthcare settings.

This year seems to have just flown by, and what a busy one it was for research and stories about sex. From philandering footballers to STI statistics we certainly got to hear a lot about relationships.

Here are some of the main stories I think made up the year in media, sex and science.

The year began with the launch of the Home Office’s report on Sexualisation of Young People a problematic review which received lots of media coverage but very little critical attention from the press. It sadly overshadowed a far more detailed and useful similar report that came out just beforehand on Sexualised Goods, Commissioned by the Scottish Parliament. (You can find discussions critiquing the Home Office review here and here with a history of sexualisation reviews from other countries and open access tools to evaluate them here)

January was also noteworthy for being the month all our G spots went missing. Who knew?

Did you know Facebook caused syphilis? No, well nor did I until in March the press went crazy for the ‘Facebook linked to a rise in syphilis’ story. This was based on some opinions from a public health practitioner who should have known better, but who press released speculations about sexual health and social media. Cue plenty of irresponsible media coverage.

It provided an opportunity for sex educators to challenge these claims and also to promote health advice about syphilis, STIs and safer sex. Worryingly many sexual health charities and public health organisations failed to engage with the story in a timely fashion, completely missing the opportunity to share information with the public. An account of how this story unfolded, the heroes and villains of the piece can be found here.

The BBC produced a groundbreaking and sensitive drama ‘Five Daughters’ in April, based on the tragic story of five women from Ipswich who were victims of a serial killer in 2006. It retold the stories of Anneli Alderton, Paula Clennell, Gemma Adams, Tania Nicol and Annette Nicholls, plus the role of the police and support agencies. It was praised for its accuracy, respectful approach and depicting the female characters in a humane way, particularly focusing on their friendships and families. A discussion of why and how the series was made can be found here.

April also saw the bizarre case of Clitoraid unfold. What began as a request via twitter and facebook to ‘adopt a clitoris’ soon was a more complex case involving a cult, unclear activities in Burkina Faso, and the support of sex educators and a sex store. A summary of the story can be found here, hereand here. Many questions about Clitoraid still remain unanswered, and have caused rifts between sex educators, activists and health/development practitioners. This bad feeling was distressing, particularly since many involved were highly respected within the field of sex education and activism – and because basic respectful approaches to international practice were ignored.

What do you do if your girlfriend ditches you and goes out with someone else? Mope? Call up your mates and hit the town? Go visit your mum? Listen to sad music? Or cut your girlfriend’s face so nobody else would ever want to date her? If it’s the latter then you’ve clearly been taking your relationship advice from actor Danny Dyer and Zoo magazine. In May Dyer’s advice column contained this shocking suggestion, which was noticed by @sarahditum and quickly spread across twitter. Dyer blamed Zoo, Zoo blamed Dyer. Nobody took any responsibility for anything. But action did get taken, primarily when people stopped complaining to the magazine and editor and started targeting advertisers with the magazine. Dyer was sacked. Zoo was forced to write an apology and feature about domestic violence. The whole sorry saga is summarised here and here.

The same month saw Project Prevention gain notoriety in the UK with largely uncritical media reports like this. Through countless chat shows, broadcast and print news the organisation suggested drug/alcohol and reproductive health services (plus other support services) were failing to manage drug/alcohol users getting pregnant. And suggested cash incentivised sterilisation programmes were the answer. (Project Prevention are only focused on sterilisation or adoption of long acting hormonal contraception. They are not interested in supporting drug/alcohol users after this – in terms of sorting out any addiction, housing/family issues, or safer sex concerns. Moreover they fail to address repeat pregnancies can be a sign of domestic abuse. Their focus is solely on preventing drug/alcohol users getting pregnant).

The media provided no real discussion of what services already exist, what they offer, how they work, where they could be improved. Without this, discussions on Project Prevention were meaningless but this didn’t stop media approaching the issue of drug/alcohol abuse and incentivised sterilisation as though this were a necessary and beneficial option, required because of gaps in existing services. Since no services were seemingly assessed it would be difficult to draw these conclusions but it didn’t stop the media. Who also ignored the concerns of drug/alcohol charities, human rights groups, and healthcare practitioners.

Nor was much investigation carried out into Project Prevention, or their previous incarnation CRACK (Children Requiring a Caring Kommunity) despite numerous publications on them in health/legal journals (see here, here, here, here, here and here)

Blogger Stuart Sorensen emerged in this debate as a voice of sanity and tireless campaigner against Project Prevention. Inviting the UK representative of Project Prevention to explain their plans for the programme in the UK then creating resources for practitioners and the public around how to tackle the organisation (all his writing about Project Prevention can be found here and on twitter)

Despite some journalists and bloggers writing about Project Prevention as though it were an established and worthwhile UK organisation, in fact it is not. Ethically in the UK practitioners cannot sterilise people who’ve been financially incentivised or who are drug/alcohol dependent. They can, with the person’s consent, suggest long acting reversible contraception (LARC), although Project Prevention do not appear linked with any existing drug/alcohol or reproductive health services. Currently they are requesting monetary donations to fund getting people onto LARC which can already be freely offered via the NHS. But the media and uncritical bloggers haven’t really considered the ramifications of this at all. The project and messages behind it are popular with media and some quarters so it continues to require vocal opposition. Not least because its focus on the poor, vulnerable and socially excluded feels like eugenics to many people. Rather than giving Project Prevention a platform we would do better to explore complex cases around reproductive health and drug/alcohol abuse, and ways to ensure services can better support addicts and their families.

In the midst of this we had a general election. Labour lost. The conservatives and liberal democrats formed a coalition. Many long term labour supporters, myself included, had become disenchanted with many of the actions of the labour party. Particularly around its use and neglect of scientific evidence to inform policy and law. (I wrote about my direct experiences of this here). The Liberal Democrats were eager during electioneering to persuade scientists to focus on ‘geeking the vote’ and made many promises around healthcare, education, academic funding, university fees and supporting science. Perhaps unsurprisingly many working in academia and science were persuaded to vote for them on this basis (I certainly was, something I am still regretting – and you’ll understand exactly why when you read this – the most personal post I’ve ever shared on this blog). For some the subsequent backtracking and u-turns of the Liberal Democrats have come as no surprise, to others of us it has come as a dreadful shock. And a sad let down not only to see the behaviour of the Liberal Democrats since they became part of the coalition, but also to note many of those who so actively courted the academic and science vote have dropped contact with us. Leaving us feeling cheated on many levels. A truly depressing turn of events.

June saw the FDA reject the drug Flibanserin – the female ‘desire drug’ despite months of media hype about this being the next ‘female viagra’ (as the media consistently and incorrectly described it). Shortly after drug development was discontinued, while later in the year Ray Moynihan’s fantastic book Sex, Lies and Pharmaceuticals highlighted further the problem of medicalisation of female sexual functioning by the pharmaceutical industry.

Also over the summer we saw a scandal break around off label use of the drug dexamethasone given to pregnant women to prevent congenital adrenal hyperplasia (CAH) in girls. CAH is a disorder that affects the adrenal glands, so a person will not make enough of the hormones aldosterone and cortisol, but will make too much androgen. One of the results of this can be girls with CAH having ‘ambiguous genitals’. Using dexamethasone to prevent CAH (and particularly to prevent girls developing male genitals) is a standard practice for some clinicians, as is offering genetic testing to parents with a history of CAH. Many endocrinologists and medics have argued prescribing dexamethasone should only happen within a controlled, supervised, trial programme (which is currently not the case). The real scandal around CAH came from a clinican who was prescribing ‘dex’ to not only prevent CAH but also to prevent lesbianism.

This case was broken by Alice Dreger and colleagues and quickly spread to the media who focused on the need for using dex to treat CAH and the circumstances under which it might be used (see here and here for examples). The media, while expressing dismay, were not as critical about the use of dex to ‘treat’ both gender and sexuality as bloggers were. The blogosphere (particularly writings from trans and intersex people) took a more politicised, critical and wide ranging approach to this story (see for example this post from Mark Simpson assisted by @quietriot_girl, which links to other discussions about dex, sexuality and CAH).

Around the same time, a separate story was broken by Dan Savage which also involved Alice Dreger and colleagues. This time alerting practitioners and the public to research being undertaken at Cornell University by Dr Dix Poppas. Poppas’ research focused on ‘treating’ young girls judged to have oversized clitorises by performing clitoral reduction surgery on them. And testing for post operative sensitivity with manual stimulation and the use of a vibrator. Unsuprisingly this led to an outcry, primarily from bloggers (rather than the mainstream media who didn’t give it as much attention). Bloggers and activists saw the research as child abuse and female genital mutilation/cutting (examples here, here and here). It also led to wider discussions around surgical interventions and intersexuality within forums and on twitter – some of which became pretty heated but were definitely of interest. Sadly even within these discussions some intersex people felt they were (as so often happens) being spoken for or spoken over. The CAH and particularly Cornell case showed us we still have a long way to go around open and respectful dialogues in this area.

While it was right to focus on both the CAH/dex/lesbianism and the Cornell /cutting stories, what proved interesting about both was they recieved far more attention and debate across the blogosphere than within the mainstream media. But both these cases still received masses more attention in both blogs and the mainstream media than the clitoraid case. Despite the Clitoraid case being equally troubling on many levels. Those of us involved in challenging Clitoraid were left wondering whether it was simply the case that when it came to the rights of African women the press and bloggers just weren’t as interested. Not a comfortable feeling.

The media tend to view the summer months as ‘silly season’ and they certainly didn’t disappoint in August, with a spectacular misunderstanding of public health data and wild claims that not only were dramatic numbers of 11 year olds on the pill, but the belief they were all using hormonal contraception because they were sexually active. In reflecting on the story health practitioners began to realise just how little journalists covering stories like this understand about young people, puberty and hormonal contraception. Or that very few young women are prescribed the pill – and if they are it’s usually for things like acne or heavy periods. A rundown of the story in its full ridiculous glory can be found here

Not to be outdone by the press, MP for Peterborough Stewart Jackson decided the best use of twitter was to insult his followers who questioned his anti sex education statements. By calling them ‘sex obsessed leftie weirdos’ and other choice insults. Accounts of which can be found here and here .

In the US a spate of suicides of teens bullied over their sexuality led to Dan Savage establishing the It Gets Better project aimed at providing messages to young LGBTI people that things can improve. Numerous celebrities, politicians, activists and members of the public have posted their stories to the project in an attempt to highlight for many young people suffering homo/transphobic bullying that life can change and is worth living. There are too many to share here but the notable and moving contributions (in my view) to discussing how ‘it gets better’ came from Councilman Joel Burns

and the staff at Pixar

This programme was unusual as it took a slightly different approach to the usual anti bullying approaches, by taking a positive and hopeful view. Perhaps unsurprisingly some critics felt it oversimplified problems, suggested that things always worked out okay, and that adulthood is an automatic escape from homo/transphobia. In particular the message that it was worth enduring hardship/distress now because a brighter future awaited proved problematic for many. (This is explored in more depth here). Debates began about whether the project was a good idea. Blogger Furrygirl robustly responded to feminist critics of the scheme. While thoughtful writer Tania Glyde took a different view, thinking around why sometimes things don’t get better – and why that happens. And how often this may not be under your control. Her amazing and moving post on this is here.

It Gets Better still requires discussion and evaluation – it would be interesting to see what a difference this grassroots project may make. But it also reminds us of the lessons many working in sexuality, sex and relationships health/education already know. Which is that we can’t give blanket messages. It is important to have positive goals, but telling people what to do rather than how to get there may not be enough. And that anti bullying messages based on oversimplistic ‘it’ll be okay’ or ‘it’s dreadful’ are unhelpful. Instead we need more tailored approaches to tackling homo/transphobia for young people, adults and families. Across schools, the legal system, media and beyond. It Gets Better may have its fans and critics, but it has reminded us many young people are at risk of bullying within the school or other spaces and we all need to take action to empower and safeguard them. Now and in the future.

During the year it became apparent that science funding and other provision for education were under threat and in October UCL scientist (and all round fabulous woman) Jenny Rohn decided to take a stand. She gathered together a merry band of scientists and practitioners and got them to back the Science is Vital campaign which resulted in a petition, plenty of blog posts on the topic, extensive media coverage, and defended science against the cuts. Oh and some really questionable singing

Oh, and this woman turned up too

November saw the 40th anniversary of Page Three – but was this a cause for celebration? Nobody seemed sure. It also marked the closure of the Teenage Pregnancy Independent Advisory Group (TPIAG) who had overseen the (then) government’s Teenage Pregnancy Strategy over the past decade. Their final report can be found here, with TPIAG warning that not taking action on teen pregnancy (and supporting teen parents) will cause problems in the future. While the Teenage Pregnancy Strategy was not without its critics (from various sources) it did commit to supporting teen mothers and identifying causes of teen pregnancy. What will happen under the Coalition in relation to support for young people, and particularly teenage parents, remains to be seen.

This month also saw the Geek Calendar project go into overdrive, with plenty of coverage, advanced orders and the opportunity to raise funds and awareness for libel reform. I was delighted to participate and hope many of you are now a proud owner of a Geek Calendar of your own!

At the close of the year the government have revisited the issue of prostitution, calling for a review into best practice in managing the issue, echoed by ACPO who have also called for a review of legal and health approaches to sex work. Media coverage on this so far has been positive, but focused more on women, not addressed male and trans workers.

The year has also ended on a similar note to how it began, with a return to reviewing sexualisation and commercialisation, this time led by Reg Bailey (chair of the Mothers’ Union) who will be looking at existing reviews in this area and deciding what else needs addressing for children and young people. Critics have already questioned why a ‘review of reviews’ need completing, and whether Bailey is the appropriate person to oversee this process.

Linked to this was the government suggestion that Internet Service Providers block access to porn which has had a mixed reception. However, debates about sexualisation continue to be a media favourite and are for the most part not based on sound research. Indeed much of it seems to just be speculation – like this claim that cheating footballers are normalising adultery. This sadly seems to be the way Bailey and others are trying to bring boys into this debate. Not exactly helpful.

During the year we’ve had to say goodbye to several people who’ve been trailblaizers in the areas of sex, education and health. Including
Claire Rayner
Professor Otto Wolff (a hero of mine who was the first and pretty much only senior health practitioner to recognise the work of agony aunts as having a relevant health role)
Actress and model Pamela Green
Cory Silverberg also pays respect to others who have passed during the year over at his blog.

Join me on New Year’s Eve when I’ll be looking back over my Sex and Relationships Predictions for 2010 and seeing how many of them came true, or where I was completely off track. And in the new year I’ll be giving you a new list of predictions for 2011.

Thanks to @bishtraining @mngreenall @SexEdUKation for their help with this blog – and checking I’d managed to remember all that’s happened this year! And for @quietriot_girl and many others who emailed me to remind me about things I’d forgotten and needed to add.

It’s nearly Christmas and you may have already got gifts for friends and family. But if you’re still wondering what last minute goodies to buy, or can stretch to one more present, then here’s a few suggestions for charities and organisations who could do with your support.

These are all programmes I feel are often not given much publicity and may not fit in the usual ‘good gift’ type Christmas promotions, but nevertheless do amazing work all year round and deserve our support.

I’ve picked 6 charities/groups who represent various different activities around sex, relationships and health. Some are faith based, some secular. Some are specifically focused to one region or country, others are international. You may want to support the one you feel most impressed by – or perhaps give a small amount to several of these very good causes.

As well as financial support there are also other ways to help these organisations so do read up on any that interest you and see if you can help them as a volunteer in the new year.

Hesperian Foundation
Hesperian is a non-profit publisher of books and newsletters for community-based health care. It produces free resources in various different languages on topics such as Where There Is No Doctor, Disabled Village Children and Helping Health Workers Learn.

Here are ways you can get involved, which don’t just involve financial donations – you can also volunteer, translate and review books, and let other people know about the work Hesperian are doing.

Jabulani Rural Health Foundation
Jabulani is a non-profit organisation that supports Zithulele Hospital and its surrounding community. Zithulele Village is situated in a remote part of the Wild Coast (Eastern Cape Province, SA). Founded in 2007 by four Christian doctors, our focus is on healthcare, education, poverty relief, environmental issues and care for those affected by HIV/AIDS.

Practitioners at Zithulele have introduced a number of innovative programmes for rural health which have been reported in The Lancet and SAMJ and include nutrition, maternal health, occupational therapy and education projects.

A short film about the hospital can be found here:

Donation information can be found here
Become a friend of Zithulele here

Scarleteen
Scarleteen is an independent, grassroots sexuality education and support organization and website. Founded in 1998, Scarleteen.com is visited by around three-quarters of a million diverse people each month worldwide, most between the ages of 15 and 25. It is the highest-ranked website for sex education and sexuality advice online and has held that rank through most of its tenure.

More info here

Donate here

Outsiders
Outsiders is a community for people with physical and social disabilities that enables people to meet, make friends, overcome isolation and form relationships. It coordinates local meet ups, provides advice and hosts numerous events to raise funds for greater advocacy for people with disabilities. It also operates a peer support network, lobbies for greater rights for disabled people, and informs health and social care practice around sex, relationships and disability.

As well as providing financial assistance there are other ways you can help Outsiders including lobbying on issues around disability rights, and assisting the organisation with research, advocacy and resources. More information on how to give here

Education for Choice
Education For Choice is the only UK-based educational charity dedicated to enabling young people to make informed choices about pregnancy and abortion.

When young people have opportunities to explore the decisions that can lead to and result from pregnancy they are better able to:
Protect themselves from sexually transmitted infections and unintended pregnancy
Make informed choices
Access appropriate services to support their choices.
Education For Choice’s work is focused on the word choice. Whilst we concentrate on the issue of abortion, as it is the issue that receives least attention, we believe that work with young people should value all pregnancy choices equally.
Our ethos is that the best outcomes of unintended pregnancy occur when the woman involved has been able to make her own informed choice.

Donate here

The New View Campaign
The New View Campaign was formed in 2000 as a grassroots network to challenge the distorted and oversimplified messages about sexuality that the pharmaceutical industry relies on to sell its new drugs.
The pharmaceutical industry wants people to think that sexual problems are simple medical matters, and it offers drugs as expensive magic fixes. But sexual problems are complicated, sexuality is diverse, and no drug is without side effects.

The goal of the New View Campaign is to expose biased research and promotional methods that serve corporate profit rather than people’s pleasure and satisfaction. The Campaign challenges all views that reduce sexual experience to genital biology and thereby ignore the many dimensions of real life.

The New View Campaign is devoted to education, activism, and empowerment. We invite you to benefit from the information on this website, and we invite your support and participation.

More information on donating and volunteering for the New View, as well as implementing its ideas into policy and practice can be found here

I hope you are able to support one or more of these charities/organisations financially or in some other way.

Thanks for your continued support for this blog. Your feedback, suggestions and ideas for content (and how to improve the blog) is always very welcome.

Wishing you a very Merry Christmas and all the best for a happy and healthy New Year.

To get people in the Christmas spirit – and the mood for giving, I’ll be sharing carols, seasonal songs and a few sketches on twitter between 1-4pm on 22nd December (GMT) on the hashtag #PsXmasCharityConcert.

If you missed it, here’s the concert in full – please consider giving to one or more of the charities/organisations listed above while you tune in!

We opened with Mariah Carey’s All I Want For Christmas Is You

Followed by Meryn Cadell’s The Cat Carol which you can listen to here. [Not really suitable for young children, anyone who feels a bit hormonal, or people who like cats]

Then it was time for a bit of reading, with the fabulous Joyce Grenfell’s Nursery School Nativity Play And George, Wise Men never do that…

I bet you’ve never heard a better (or madder) version of The Little Drummer Boy than this one by The Klezmonauts.

It’s a Christmas tradition in our house that my dad reads King John’s Christmas as part of our family concert (he does it beautifully). So it felt apt to include it in my virtual Christmas Concert.

Next it was time for some Christmas kitsch – and it doesn’t get much kitscher than Eddie Dunstedter and his organ. I feel like I need a pair of heels, a cocktail and a Christmas pinny to really get into this one…

And if that wasn’t camp enough, it was time for some innuendo with Larry Grayson asking ‘Who’s stuffing your turkey this Christmas?’ (Go on, you can tell me!)

Do you believe in reindeer and the magic of Christmas? Of course you do! It’s only those pesky physicists who try and spoil things with all their logical explanations. Bah humbug!

Another song due after that, and it was over to Si Cranstoun and a very jolly Miss Santa Claus (he’s part of the Dualers – who are fab!)

What could be more seasonal than a song about an Angel Gabriel by LAMB?
I can fly
But I want his wings
I can shine even in the darkness
But I crave the light that he brings

Hoping you have someone in your life who make you feel this way.

On a lighter note I asked if people were familiar with the term Camp As Christmas? You will be after watching Bearforce 1 and ‘Christmas is here’ (which frankly ought to be the Christmas number one IMHO)

Next it was time for an activity for all the family – and kids of all ages. The Santa Application form (which I use in teaching questionnaire design – only at Christmas obviously). Still time to get your application written!

Obviously it wouldn’t be Christmas without a bit of Judy Garland, and the tearjerker anthem Have yourself a merry little Christmas

Last up in the virtual concert was my favourite carol In The Bleak Mid Winter which has the most beautiful words written by Christina Rossetti. I have a bad habit of ruining carol services by blubbing my way through the final verse of this.

Thanks for joining in my charity concert – either here or on twitter, and remember this was all for the good causes listed above, so please give them your money or your time if you are able.

Merry Christmas!

*

If you ever wanted to see how the media simultaneously loves and destroys stories on sex and science, this week we had a classic example of truly bad sex coverage. All based on a conference presentation that suggested low libido in women could be detected through brain scanning.

I’ll move on to the research itself in a second, but first let’s look at some of the media coverage this study generated. Women with low libidos ‘have different brains’ yelled the Telegraph’s MEDICAL CORRESPONDENT (although let’s be fair they probably didn’t pen the headline). The BBC went with a similar angle (and equally daft headline) ‘Libido problems ‘brain not mind”. The carnival of largely poor and uncritical coverage can be found here.

From the press coverage you’d be forgiven from thinking there’d been a massive new scientific breakthrough here. The brainz/sex/laydees combo is a heady mix for journalists – and probably why this conference presentation at the Annual Meeting of the Society for Reproductive Medicine was probably selected for press release. The abstract for this presentation can be found here (although I’ve taken the liberty of printing it in full below)

[O-199] CEREBRAL ACTIVATION PATTERNS IN WOMEN WITH HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD) VERSUS WOMEN WITH NORMAL SEXUAL FUNCTION.

Oral Presentation: Sexuality Special Interest Group

So this is the presentation that spawned massive global coverage. A conference presentation based on an exploratory study of 19 women with self identified sexual problems and 7 ‘normal’ controls (whatever that means). This is a very small sample, and is not from a peer reviewed publication, and it makes grand claims about neurological activity and sexual functioning which may not be as exciting as they first appear. Without access to a paper to judge, however, we really don’t have much more to go on.

Fortunately a few smart bloggers who know their stuff about neurology and sex have done a very good job in critiquing the study based on what they can tell from the abstract. These include:
Cory Silverberg on why ‘Sex Researchers Want Your B-R-A-I-N-S’
The Neurocritic explaining ‘Media HSDD: ‘Hyperactive Sexual Disorder Detection’
Neuroskeptic also explores the research in their post ‘Brain Scans Prove That The Brain Does Stuff’

I’ve been bothered on two levels about this research. Firstly, the generalisations about neurology/sexual functioning, which the bloggers linked to above do a far better job than I could in dismantling. I’ve no doubt there are interesting things to explore in relation to brain/behaviour and sex, but am not convinced studies like this are really adding to our understanding of sexual functioning.

But what worried me more is the way the media responded to this story. The conference presentation was distributed to the media over the weekend, which is when journalists first alerted me to it. That means (at least some) journalists had a couple of days at least to research and write this story. It also means that a fair number of journalists were talking to academics like me (or other therapists/activists) who were telling them to find out….

- Who funded this research? (That’s important given the influence of the pharmaceutical industry in this area, particularly with their role in medicalising HSDD)
- The problem with the very small sample size
- The issue that this study was only appearing in the form of a conference presentation and had not been submitted to peer review for a journal, nor published in a format people could read to form conclusions about the robustness of the research
- How sexual dysfunction and ‘normal’ were measured and how women were assigned to these categories
- What measures were used to test arousal, and did those seem reasonable in terms of producing similar responses in participants
- Whether the research made any sense to neurologists, and particularly to talk to neurologists and get them to give their view (and to use this to interpret the research when writing it up)
- Where this work fits within the wider context of HSDD – not least given it’s very recent history with the ‘desire drug’ Flibanserin being abandoned by the drug company who created it, the British Medical Journal debating the problem of medicalisation of female sexual functioning, and Ray Moynihan’s groundbreaking expose on the disease mongering of HSDD in his book Sex, Lies and Pharmaceuticals.

It was, after all, only a couple of weeks ago the press were telling us HSDD doesn’t exist. But two weeks isn’t long in media land and certainly nobody seemed to do any searching to highlight this in the pieces they were writing.

In fact the main format for these stories was to rehash the research uncritically, talk in an alarmist manner about the prevalence of women’s problems but explain their lack of sex drive was ‘in the brain’. With a couple of therapists or medics quoted cautioning about overgeneralising on HSDD – but nobody specifically taking on the research. That remains a common problem with all coverage of this kind. A token spokesperson’s required to give ‘balance’ but that usually still approaches the original research as though it’s robust enough to pin a story on – rather than the research itself that requires a thorough appraisal.

Remember many journalists reporting on this story were MEDICAL or HEALTH or SCIENCE correspondents, many of whom were actually at the conference. So they could, and should, have asked questions about the study based on the things I’ve listed above. If you’re a journalist specialising in health/science these should not be particularly difficult things to ask. In fact it should be the first things you question on. A basic search around recent coverage on HSDD should also have alerted any journalist (regardless of speciality) that this is a controversial area full of problems with funding, bias and spin.

Some of the journalists I heard from decided, after reflecting on the study, simply not to report on it. Fair enough you may think, they decided it wasn’t that robust and wasn’t worth writing about. However this is as problematic as writing about the study uncritically. If you don’t talk about a study because you don’t give it much credit the public won’t know why you’ve got a problem with it.

A far more appropriate response from the media should have been to take the story but ask questions about the findings, put them in context, and talk to the public about what kind of things can cause lack of desire, why it’s a problem to medicalise these factors, and where scientists are trying to do this (as may have happened here).

Even if all your competitors are gushing over a small sample conference presentation that sounds sciencey but actually isn’t that informative, if you’re the only person who tackles the problems with the science and the wider social ramifications then you have an exclusive. Again, many journalists were given the opportunity to do this but they chose either to report the study uncritically, or not cover it at all.

The problem we have at the moment is the mainstream media appear incapable of understanding or accurately reporting sex science stories – even when they are given information to enable them to do this. And while we are rightly complaining about the activities of the pharmaceutical industry, the problems of medicalisation and the poor research that accompanies this, we also need to note the media are a major cause in the misrepresentation of HSDD to the public.

Perhaps it might be more accurate to say (in the words of blogger and consultant @mngreenall) ‘hacks have “different brains” that “light up” when there’s guff to be written about sex’. Certainly it seems if there’s a sex science story that promises a whacking gender difference and an oversimplistic answer to a complex problem the media are guaranteed to give it coverage. No matter how weak the research may be, nor how serious the repercussions can be to the public who desperately need quality information to reassure them about their sexual anxieties.

It’s so depressing to see stories unfold like this, and at such times it’s always good to fall back on ‘women know your limits’ for a more biting and ironic take on womenz brainz….

* Image source here

Last Friday drug company Boehringer Ingelheim presented evidence to the FDA’s advisory panel on their drug Flibanserin. This product, designed to tackle Hypoactive Sexual Desire Disorder (HSDD) in women had already been given plenty of media coverage focusing on ‘Pink Viagra’, and raised concern from scientists, healthcare staff, therapists and activists. You can see a summary of the case up until the hearing here. Meanwhile Neuroskeptic has an excellent discussion on the problems with the drug while the New View Campaign (who gave evidence at the hearing) have produced a number of really helpful fact sheets to help you understand the research behind Flibanserin.

Why did the FDA Advisory Panel say ‘no’?
The FDA rejected the application to approve Flibanserin for several reasons. They were concerned about the materials used in trials to measure sexual response, the trial outcomes (which suggested Flibanserin did not perform much better than placebo) analysis of the data, and overall management of the trial. The FDA did not, however, dismiss HSDD generally and indicated it was a problematic condition they recognised.

Those who have raised concerns about Boehringer Ingelheim’s marketing of Flibanserin, it’s attempts to increase focus on HDSS within medical education and the quality of the research on the drug were relieved to hear the FDA’s decision. However, critics of the concept of medicalising women’s sexuality were concerned the FDA accepted the diagnosis of HSDD which is seen by many as problematic.

Boehringer Ingelheim have since issued a press release detailing how they will continue to research HSDD and continue their trials on Flibanserin. The result from the FDA, although fair, comes as very bad news to the company who have already invested heavily in the drug in the hope of making millions from sales if they can get it approved.

The FDA Advisory Panel’s decision will be formalised in the coming months. What seems very obvious is concerns raised about the drug have been heard but only in part and certainly there is no sign Boehringer Ingelheim will discontinue trials of Flibanserin at this stage.

How about the press coverage of this case?
The media have handled this case better than previous drugs aimed at treating HSDD. Although in the run up to the hearing there has been a lot of coverage for ‘Pink Viagra’ there has been some more accurate and critical reporting. Certainly since the FDA decision has been released there has been some particularly excellent coverage such as this report for CNN by Jennifer Terry.

There are, however, lessons to be learned from the media’s approach to this case. Journalists in the main did not investigate the claims made by scientists such as myself about the marketing of Flibanserin, the approaches by Boeringher Ingelheim took to medical education, or the quality of the research. Indeed many journalists said they couldn’t find the research – and that’s because Boeringher Ingelheim did not publish it in any peer reviewed journal. This alone should have rung major warning bells for journalists but generally didn’t. So we need to be aware that while there is now some critical coverage about the medicalisation of sexuality there is also a long way to go to get journalists to ask basic questions about drug company funded research in this area. It’s important the media gets better at this because, aside from getting better stories to cover, the focus on finding a pill to fix female sex problems won’t go away.

What should we be aware of now?
Boeringher Ingelheim have indicated they will continue with their trials of Flibanserin, they may well reapply to the FDA with new trial data or may apply to the European Medicines Agency (EMEA) for approval.

Debates about the diagnosis of HSDD (and sexual problems) will also continue as the DSM V is developed.

Journalists, healthcare providers, therapists and the public need to be aware of the problems with the research that led to the FDA’s decision and further scrutiny needs to be applied to the company and the drug in the coming months. It would certainly be helpful if healthcare staff challenged the medical education for HSDD awareness funded by the company and the media applied a critical lens. We will also need to be alert to other drug companies also working on similar products.

We also need to be careful to avoid getting into debates about whether a pill is needed or whether women have sexual problems, as has been the case in the current coverage of Flibanserin. This has missed the wider aspects of marketing, poor trial design and other research questions that really needed to be talked about. Instead we’re often left with an argument that in questioning medicalisation of female sexual functioning we’re somehow denying women have problems.

So as this latest chapter in the medicalisation story closes, let’s be very clear. Women do experience sexual problems that cause them distress, discomfort and dissatisfaction. These are often linked to other factors and do need attention, but they are not a clinical condition or a dysfunction, and they do not require a new and separate diagnosis. A summary of common reasons women experience problems with sex can be found here.

Helping women involves highlighting the wide range of reasons they may experience problems with sex, the different solutions to those problems and to focus on educating women and their partners about the wide range of sexual experiences they may enjoy. It also means continually challenging anything that may restrict and pathologise female sexual desire.

The FDA decision is good news for science, healthcare, activism and for women’s sexual lives. However the push to find a medical solution to female sex problems is not going away and I will continue to question, challenge and update you on what’s happening. Although I hope you’ll also be doing this too!

On June 18th pharmaceutical company Boehringer Ingelheim will be seeking approval from the Food and Drug Administration (FDA) for their drug Flibanserin (which may be traded under the names of Ectris and/or Girosa).

This is an antidepressant style drug which Boehringer Ingelheim claim is a treatment for low/lack of sexual desire in women (aka Hypoactive Sexual Desire Disorder or HSDD). It must be taken every day and for up to a month before any benefits may be noticed. How long it should be taken for after that is not clear.

It has been difficult to judge the efficacy/effectiveness of this drug because to date no trial data has been published in a peer reviewed journal. Instead data was presented at a conference last November based on combined data from a number of trials. This combined data indicated a significant difference between the drug and placebo although it was only one more sexually satisfying experience per month on Flibanserin as compared with placebo. There is little information available about how long the drug must be taken for, potential side effects and what happens during/after withdrawal. A summary of activity on this product to date can be found here.

Despite a lack of clear data about the product, its effectiveness or how it has been evaluated, Boehringer Ingelheim has already focused on marketing to the public with activities including a glossy website aimed at women called Sex Brain Body. Messages outlining the prevalence of HSDD and related issues are also shared frequently via @SexBrainBody on Twitter. They have also been approaching practitioners to put their name to pre-written pieces to go into journals. These detail the prevalence of HSDD to be aimed at GPs and other healthcare staff along with hosting numerous ‘training events’ (described as ‘round table discussions’) for practitioners to learn more about HSDD and CME activities for medics such as “Female Sexual Health: Recognizing the Impact of FSDs on Patient and Partner and Implementing Clinical Strategies for Overcoming Communication Barriers”. In addition for the last 12 months the company has also paid a number of sexologists to design marketing materials.

What is HSDD and does it exist?
Women do experience psychosexual problems, as well as relationships difficulties or dissatisfaction with sex/relationships. You can see these summarised in an answer I recently wrote for NHS Choices.

Obviously with many potential causes of problems there are many potential solutions/responses. This might include basic health information, adequate reproductive health care, improved communication with a partner, healthcare for other problems or relationships counselling.

Concerns have been raised by the suggestion that not wanting sex or experiencing low sexual desire is a clinical problem requiring a pharmaceutical solution as a first port of call.

It was all about your hormones, now it’s all in your head
In the past five years we’ve seen some interesting (and worrying) developments in the area of drug development for HSDD. For several years the general view was women’s lack of desire was linked to hormonal deficits (specifically Testosterone) with hormonal patches designed to ‘treat’ the problem. These performed poorly at trial and were not approved by the FDA (although did get approval for use in Europe). A systematic review of all trial data indicated the Intrinsa patch was not effective at dealing with low desire in women.

The focus has now shifted to seeing women’s lack of desire as a neurological problem, with Flibanserin working in a similar way to an antidepressant (indeed it was developed as an antidepressant but was not fit for purpose). The naming of the promotional site as ‘Sex. Brain. Body’ particularly shifts attention towards female desire problems as being psychological, complex and emotional.

Intrinsa was only designed for women who had low desire following surgical menopause, whereas Flibanserin can be taken by any woman diagnosed with low sexual desire. Already we have seen practitioners associated with Boehringer Ingelheim working on Flibanserin also suggesting the contraceptive pill reduces desire which is one market which may benefit from having a pill to boost arousal.

Challenging the medicalisation of female sexual problems
There have been a number of efforts to challenge the medicalisation of female sexual dysfunction and to ask questions about Flibanserin. These include the New View Campaign, journalist Ray Moynihan’s forthcoming book Sex, Lies and Pharmaceuticals and Liz Canner’s documentary Orgasm Inc. While Paul Joannides has used humour to focus on problematic aspects of the drug.

The response by the Boehringer Ingelheim has been to focus on presenting high levels of female sexual dysfunction to practitioners and the media, and reinforcing the message HSDD is extremely prevalent and highly distressing. Those who have criticised the company or the drug have been accused of ignoring women’s plight or dismissing problems.

This is unfair and inaccurate. It is perfectly reasonable to question any drug that is being marketed, particularly in terms of its effectiveness, safety, marketing and purpose. Rather than denying women’s problems those questioning Boehringer Ingelheim are mostly long term activists for women’s health and sexual wellbeing.

What can you do?
Write to the FDA
This needs to be done by 3 June (can do this via email or fax). Contact details are:
Kalyani Bhatt
Center for Drug Evaluation and Research (HFD-21)
Food and Drug Administration
5600 Fishers Lane (for express delivery, 5630 Fishers Lane, Rm. 1093)
Rockville, MD 20857
Phone: 301-827-7001
Fax: 301-827-6776
E-mail: Kalyani.Bhatt@fda.hhs.gov

In particular you may wish to focus on the following in your feedback via the New View Campaign
“Please write to the FDA before June 3 about Flibanserin. All the information you need is on the FDA website. Write about side effects worries, poor efficacy in the trials, your concerns about the target population of young women, the outrageous marketing campaigns now underway with actress Lisa Rinna and others, the poor efficacy in the European trials that is never mentioned, the emphasis on HSDD (a soon to be extinct designation), etc. Be specific and be personal!!”

Sign the petition
The petition against Flibanserin and the medicalisation of female sexual functioning is hosted at Change.org. Please share this widely on twitter, your blog, forums, through health groups and listserves. It will be presented to the FDA at the hearing on the 18th June.

Encourage the media to focus on this as a women’s health issue, rather than a pro/con debate on whether HSDD exists or whether women should/shouldn’t get help.

If you work within healthcare encourage colleagues to look critically at this drug, ask questions about why trial data hasn’t been published/subjected to peer review, and consider wider ways we can enable women and their partners.

This is a very important issue in sexual and reproductive health. It is extremely worrying the FDA are being asked to approve a drug which has not performed particularly well at trial, and which has not been published in any peer reviewed journal to allow the scientific community to investigate it. It is also concerning that female sexual responses which may be distressing are being reclassified into a clinical condition.

Today’s Times Weekend focuses on an important yet taboo issue – Infertility. ‘Sex, fertility and commitment: what men really think’ includes in depth interviews with several men about the topic. While it’s right to talk about this issue from a male perspective, there are messages within the feature that are worrying in relation to sex, orgasm, fertility and gender. Not least because the issue of sex is not covered in any depth, but what is discussed about sex and orgasm is misleading.

Part of the feature focuses on an interview with Lord Robert Winston, a recognised pioneer in fertility treatments. He states: “Many years ago I did a study that, to my great regret, was never published. It was on women who were not orgasmic. We showed a clear correlation between women who did not enjoy sex and unexplained infertility. The study indicated that women who didn’t achieve orgasm and were having IVF were more likely to experience unexplained infertility”

This is troublesome for several reasons. Firstly it is always difficult when practitioners talk of research they’ve done but never published. It means we have no idea of assessing the work, and it won’t have been subjected to peer review. If we’re hearing about a study it needs to be treated according to standard academic conventions. Which usually include noting other evidence in the area. As in this case there is an established body of research on sexual functioning and fertility that has been steadily growing since the 1970s. This is not discussed.

The idea of orgasm as something to ‘achieve’ has long been a worry within the sex research community, not least because it sets up sex as something that must end in orgasm and prioritises orgasm as the main focus of sex. It overlooks wider areas of pleasure couples may explore. And in relation to fertility these aspects are crucial.

For couples looking to enjoy sex within the confines of infertility treatment the Times represents sex in a narrow way, with orgasm as end goal, something you ‘achieve’. It does not help the readers appreciate a more varied approach to pleasure and affection which may be vital to a couple where sex is increasingly becoming only about conception. It gives no guidance on how that might be explored. Something we might expect when headlines promise a discussion of sex and fertility.

Moreover it does not fully explore the wider and more complex issues relating to sex and infertility that result in sexual problems. Just a few examples include the stress of treatment, anxiety about fertility, fears of being childless, relationship breakdown, preoccupation with having a baby, and the cost of treatment (if one is paying privately). While these are all talked about within the Times interview they are not really presented as a clear explanation of a complicated problem that contribute to psychosexual difficulties. Instead the piece highlights women’s lack of orgasm/sexual pleasure as a major contributor to infertility.

We know women’s fertility problems and psychosexual issues are intertwined (see here and here). However the nature of this relationship is complex. In some cases psychosexual dysfunctions lead contribute to infertility, while in others it may be the anxiety around fertility problems or undergoing infertility treatment that leads to psychosexual difficulties (see for example here and here).

Men’s psychosexual dysfunctions similarly experienced, regardless of whether it is the man or his partner who has the clinical problem (see here and here). Indeed if a couple is struggling to conceive and the man is unable to get an erection or is struggling with premature ejaculation (during intercourse or masturbation) it adds to the strain they are already under. Given the Times’ feature focuses on men, sex and infertility it is somewhat worrying this issue is not fully explored.

For women and men sexual pleasure is possible without orgasm. And while some theories have argued women need to orgasm to conceive, this is not the case. Discussions that focus on sex only in terms of orgasm miss the wider pleasures couples may experience, and also overlooks more important questions about the general quality of couples’ relationships. The Times could have used this opportunity to explore how couples might experience this, but they sadly failed to do so.

From the reporting of Lord Winston’s comments in the Times report readers could be forgiven for thinking women can control their fertility by making more of an effort to enjoy sex or having orgasms. This massively oversimplifies the wider body of research on this area.

Healthcare professionals, therapists and sex educators also need to take greater responsibility in this area. There is plenty of evidence about psychosexual problems and infertility. What we lack is clear advice programmes for couples that focuses specifically on addressing those problems as they arise, and to combat them in the first place with support and information about pleasure and intimacy that is not goal oriented to the ‘achievement’ of orgasm. We need more research on this topic and more training for professionals working with couples to help them maintain a positive relationship under highly stressful and often very distressing conditions. Part of the reason couples do struggle in this area may well be to do with professionals failing to provide this information in a timely fashion.

The issue of infertility is still taboo and highly emotive. Any practitioner talking about the area needs to do so in a way that fits with current evidence based practice and focuses on couples not women or men. We also must ensure advice given does not make people feel they have contributed to their infertility by a lack of female orgasm, which is likely to scare anyone considering trying for a baby – whether they have fertility problems or not.

The Times undoubtedly covers the male experience of infertility with their case studies. But given its focus was on sex and infertility it fails to engage on this level and misses a vitally important opportunity to help readers with a major worry couples struggle with.

Last November you may remember drug company Boehringer Ingelheim reported at a conference on their trials of a drug called Flibanserin, aimed at treating hypoactive sexual desire disorder (HSDD) in women. In lay terms HSDD means a lack of sexual desire, sometimes also described as a lack of libido.

The trials did not indicate strong findings individually, but with combined data from different country sites it suggested a women who took the drug reported 0.7 more sexually satisfying sexual experience per month as compared with placebo. You can read a summary of the history of Flibanserin, information about the trials, details of how the drug company have tried to involve practitioners and appraisals of the drug and trials here.

While aspects of the drugs effectiveness and safety long term are still being investigated, and while approvals are being sought from the FDA and EMEA the drug company appear to be continuing efforts actively promote the concept of HSDD.

Late last week the company released findings from a survey of women with low desire and associated distress at a women’s sexual health conference. Dubbed the DESIRE study (Desire and its Effects on female Sexuality Including Relationships) it reported on 65,129 women ages 18-88 from five European countries. Participants completed a computerised Decreased Sexual Desire Screener (DSDS) a five-question diagnostic tool which is apparently designed to assist “non-expert clinicians in the clinical diagnosis of generalized, acquired Hypoactive Sexual Desire Disorder (HSDD)”. 7,542 (11.5% of original sample) answered “yes” to all four questions and 5,098 (8% original sample) women further chose to participate in the in-depth survey.

It’s not clear what participants were asked in the survey, nor whether these women were part of the wider Flibanserin trials. But we can see the DSDS screening tool, which asks five questions to which you should answer yes or no:

- In the past, was your level of sexual desire/interest good and satisfying to you?
- Has there been a decrease in your level of sexual desire/interest?
- Are you bothered by your decreased level of sexual desire/interest?
- Would you like your level of sexual desire/interest to increase?

In a fifth Yes or No question, women are asked to note any factors from the following list they feel may be contributing to a loss of sexual desire or interest.
- Medications, drugs or alcohol you are currently taking
- Pregnancy, recent childbirth, menopausal symptoms
- Other sexual issues you may be having (pain, decreased arousal or
orgasm)
- Your partner’s sexual problems
- Dissatisfaction with your relationship or partner
- Stress or fatigue

If you say ‘yes’ to questions 1 to 4 and ‘no’ to all the questions in number five you can be classified as having HSDD.

However, let’s go back and look at this study again. Firstly the title of it – DESIRE. It’s unclear if this is how it was introduced to participants, but it is worth noting that using potentially coercive titles in study acronyms is ethically frowned upon in research. Regardless of whether participants were told this was the name of the study, the branding of the research as ‘DESIRE’ is certainly making a point and one might add is part of an overall marketing strategy.

Moving on to look at questions 1-4 again. They don’t contain clear parameters so ‘in the past’ could mean anything from ever in your life to the last few weeks or months.

They’re also vague ‘has there been a decrease in your level of sexual desire/interest?’ A decrease compared to what? How I’ve felt over the course of my life? How I feel now as compared to when I met my partner? How I feel with my current partner compared to how I felt with a previous lover?

See also ‘are you bothered’. Well, maybe I’m bothered because my partner bugs me I don’t seem to want sex enough. Or maybe my partner’s great and never pressurises me but I still feel inadequate. Perhaps I feel bothered about a lack of desire not because I don’t feel any, but because I’m not in a relationship currently. Or maybe I’ve lost desire for reasons I understand, it does bother me, but I also know that the situation may change or I can do something to solve the issue. Being ‘bothered’ can mean very different things to different people at different times in their relationship.

The questions are also leading. ‘Would you like your level of desire/interest to increase?’ Well most of us would probably say yes. But even if we did say this, does it really tell us much. If I say I don’t want my levels of desire to increase it may not also tell you that I would like the opportunities to explore pleasure to be more forthcoming. Or perhaps I’d like more opportunities to have the time to spend on intimacy.

If you’re setting up a diagnostic you need to be really clear about what it is you’re asking people to measure their experiences/behaviour against. Otherwise it becomes all too easy for people who’re probably not that troubled by something to be classed as someone who is in difficulty.

Let’s not lose sight of what are the main causes of desire problems in women – see how many of these you consider to be a ‘medical’ condition:
* Concerns over body image
* A lack of sex education or knowledge how your body works
* Not knowing what turns you on, or the inability to share what does turn you on with a partner
* Psychological or physical health problems (including sexually transmitted infections)
* Past or present sexual abuse or domestic violence
* A partner who has a sexual problem
* A partner who does not know how to turn you on effectively
* Relationship difficulties including arguments or jealousy
* Being overworked and lacking support from family and/or partner
* Having a young family (particularly if there’s little support provided to care for them)
* Concerns over fertility, problems with contraception use
* Lack of privacy to relax enough for sex
* Poverty and related issues of limited access to healthcare
* Focusing on vaginal sex instead of wider sexual activities, particularly clitoral stimulation

Aside from the DESIRE study a ‘patient registry’ will now be collating data on women classified as having HSDD who will be followed up long term. This will be supported by an ‘unlimited grant from Boehringer Ingelheim’ (see press release above).

What’s interesting about the reports on the DESIRE study and launch of the patient registry is there is no mention on the press release about Boehringer Ingelheim’s development of medication specifically to treat HSDD. This is important if you need to put both their investment in this study and the registry in context.

Sadly the media covered this story uncritically and without asking key questions about it. Not least about the funding of the research, registry and additional studies being conducted on medications to ‘treat’ female desire disorders.

Instead we heard coverage that women with a lack of desire suffer from emotional distress, in reports that indicated this was a widespread crisis that needed immediate attention.

Now many women do report dissatisfaction with sex, but that does not mean they are dysfunctional, nor does it mean they are always distressed. Problems around desire affect women and men, gay and straight, partnered or single. And they can be due to a variety of often interrelated factors – physical, psychological and social.

What we are currently seeing is a shift towards setting up a lack of desire as a widespread, distressing, clinical condition that requires drug treatment as a first port of call.

There are questions to be asked about why a drug company would invest in surveys and patient registers to indicate there is a disorder, while at the same time creating medication to treat this condition.

[Non UK readers may be wondering what the 'am I bovvered?' phrase in this title refers to. It's a catchphrase of a character, surly teenager Lauren Cooper, in UK comedy programme The Catherine Tate show, shown in the picture at start of this blog]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system created by the American Psychiatric Association to enable those working in healthcare to research, diagnose and treat mental health problems. It is not without controversy with critics arguing over each iteration of the manual more and more behaviours are medicalised and the DSM is tainted by the influence of drug companies with a vested interest in creating disorders in order to provide treatments. Supporters argue having a system of managing our understanding of mental disorders improves our approaches to research and care for those experiencing mental distress.

Today sees the launch of the draft version of the latest incarnation of the manual – the DSM5. It’s been worked on over the last decade and you can now see how mental disorders are being conceptualised (including what disorders have been amended, removed or added to). The whole draft is available here although I am most interested in how sexual functioning, gender identity and paraphilias are being approached.

In particular hypersexuality appears to be moving towards supporting diagnostics around sexually addictive/compulsive behaviours, which requires close attention as we already know this is one area full of very poor science, political and faith based ideology and a whole slew of homespun (but largely unevaluated) therapies.

If this is to be included in the DSM5 there needs to be a strong evidence base underpinning anything we want to label as ‘hypersexuality’ and robust reflections on how we classify problematic behaviour to ensure we don’t pathologise certain forms of sexuality (ie adultery, masturbation or alternative relationships) that particular faith based and neo conservative groups/professionals disapprove of.

The classifications around gender identity have proved controversial with critics questioning whether such guidance should be developed – particularly given a weak evidence base in this area. You can see how it is being approached in children here (approaches for adults also outlined in this part of the DSM5 draft). Mainly the debates around the classification in children have focused less on the issue of identifying problems and more about evidence based evaluations of treatment interventions for young people.

Sexual interest/arousal disorder in women is also an issue requiring close attention as we know this is an area where there’s been an ongoing issue about medicalising female sexual behaviour, suggesting women who don’t want sex for practical, relationship or health based reasons require hormonal or SSRI-type interventions.

You can expect to see discussions of this particular classification on sex blogs in the coming weeks, although it’s worth also looking at the additional classification aimed at men, and compare how these are new classifications as distinct from existing categories of orgasmic disorder aimed in women and men.

The existing DSM classifies difficulties in experiencing orgasm as a dysfunction, while the proposed new version would add to this lacking in desire for sex. Some people will welcome this seeing the lack of desire as the barrier to orgasm, others may conclude that there are many reasons women and men don’t feel desire or experience orgasm and classifying them as a mental disorder may be overmedicalising a range of normal human sexual responses.

If you’re interested in how we understand sexuality and human sexual behaviour I’d recommend reading through the entire list but focus your attention particularly on what’s being proposed as now needing classification, what’s being subsumed into existing categories and what established diagnostics look set to remain.

From this you should consider the evidence (shown by each category) and see whether you feel this is fair, balanced and whether it comes with any conflict of interest (you may need to track down the cited papers to do this). You could also reflect on what categories are being added, who is suggesting them and who might benefit or face discrimination from them should they be classed as a mental disorder. You may also want to think about what happens if any categories are added to or removed from the DSM – in terms of how we’ll be approaching research, therapy, drug treatments or surgery for sexual dysfunctions, and gender identity disorders and how those plus legal sanctions may be applied to the classification of paraphilias.

I’m not arguing here that all the items listed in the ‘sexual and gender identity disorders’ aspect of the DSM should be overlooked (for example nobody’s going to dispute paedophilia is a problem, although we need to be sure the way we classify this means those anxious about being potential abusers can get help and treatment). Yet we do need to cast a critical eye over some of the definitions activities that might come under the umbrella of fetish and kink, and also problematise those who apparently have too much or too little sex (or interest in sex).

No doubt colleagues far better versed in understanding mental health classification will be discussing the ramifications of the DSM5 draft in the coming weeks and I’ll add their reports to this blog.

In the meantime you have until 20 April 2010 to respond to this or any other aspect of the DSM5 draft. I would recommend we all do this as individuals or collective groups of practitioners or activists as this process will be used to inform how we define, research and treat mental disorders. If you feel there are particular areas which should be included or excluded from the DSM now is the time to have your say.