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.

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.

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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.

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]

First off, after blogging about Flibanserin I was contacted by Boehringer Ingelheim wanting a right to reply. So their letter is now added to that blog, which you can read here.

More 4 ran a short piece about the drug, featuring the very excellent Katherine Angel. This piece ran to the standard format that many media outlets took. It was presented as the ‘fun’ piece at the end of the news, and didn’t explain the drug completely. Interestingly within the piece one interviewee (the features editor for Woman magazine) described a scenario of a wife feeling pestered into sex by a husband – an upsetting situation and one that could be addressed through better communication. But not one that a drug might fix. And yet this was presented within the report in the context of a female libido problem that scientists should be working to ‘fix’. And sadly, as with countless other reports on this issue, the More 4 piece ended with a typical jokey response, with the anchorman describing Flibanserin as ‘the cure for creeping hands’.

Christine Ottery wrote a fantastic piece for The Guardian outlining the drug but with a focus on the wider issues of women’s sexual functioning. Meanwhile blogger Laurie Penny took up the political aspects of what the drug might mean to women in her piece (simultaneously published for Morning Star and Liberal Conspiracy). Both Christine and Laurie’s pieces are well worth a read – and particularly the responses. It’s interesting to me if you frame this debate within a health or sexual rights issue people tend to listen more than if you place it within a more feminist account.

The New York Times ran two pieces about medicalising female desire generally which you can read here and here. While Cory Silverberg returned to the debate and referenced a couple of fantastic blogs he’d spotted on Flibanserin.

The San Diego Union Tribune focuses on medics involved in consulting on female sexual dysfunction products, while Scottish paper The Herald compares male and female sex drugs. I wanted to like the Herald’s piece but a quick glance suggested the writer hadn’t really researched the area and seemed to have relied on a poorly written piece about ‘what women want’ to argue sex researchers can’t agree about what excites women, and ends with the statement “comparatively little research goes into combating killers of the developing world such as malaria” – which is just not true. It’s very annoying when you’re requiring journalists to write intelligently about the marketing of drugs if they don’t get basic public health information correct.

In more helpful coverage Agony Aunt and medic Miriam Stoppard wrote a helpful lay summary of female desire problems – along with some practical solutions.

And on a similar note, today I discussed Flibanserin and more specifically issues of female desire on BBC Radio 4′s Woman’s Hour, with veteran Agony Aunt and writer Katharine Whitehorn. You can hear that discussion here.

One thing that has been brought to my attention during the period of time Flibanserin’s been in the news, is the lack of awareness about the development and marketing of the drug by many therapists or those working in sexual health. Journalists have told me they’ve had a struggle to find people who can talk about the drug in any informed way. They’ve had no shortage of therapists and others able to talk about women and desire, but they’ve noted that either therapists/educators hadn’t heard of Flibanserin, or hadn’t followed its recent progress, nor were able to interpret or understand the clinical data from the trials.

In fairness to those working in therapy/education the drug trials haven’t been reported in any peer reviewed journals, but some parts of the data were released to the public (see my original blog linked above). It is worrying that those working in this area are not keeping up to speed with the development of drugs, the debates around medicalisation, and the ability to read trial data. It’s one reason that drug companies can unduly influence practitioners – if said practitioners are not aware of wider political debates or able to critically evaluate evidence. So a big take home message from this is about better education for those involved in therapy/sexual health – and particularly those willing to talk to the media.

It’s also worth correcting a few errors that have appeared in the media following launch of the Flibanserin trial data. Flibanserin is not the ‘female Viagra’ (despite the lead researcher for the Flibanserin trials using that term). Viagra works on the circulatory system and it increases blood flow to the penis. Flibanserin works on neurotransmitters and promotes feelings of desire.

Some media reports have suggested the drug will be on sale in two years time. This is also inaccurate. At this stage the drug is still undergoing trials and has yet to be approved for safe use. So there will be a period of time (unknown) before it becomes publicly available, and we have seen other drugs fall at this point if the FDA or EMEA don’t pass them for public use. If/when Flibanserin is made available it won’t be on sale or an over the counter product, but will be on prescription only. And in the UK this will be limited based on cost.

I’ve seen media coverage stating you take the drug when you want sex. This is also incorrect. Flibanserin is an anti-depressant style drug and to get any effects you have to take it daily for a set period of time. We don’t yet know what the side effects are from withdrawing from the drug, or long term use. But we do know it’s not a ‘sex smartie’ to take when you want to have sex.

Obviously a lot of the coverage of the drug has raised concerns women have about desire and arousal. I’ve noted these worries and I’ll be creating blogs and handouts for the new year that address these issues. After all, there are many reasons women go off sex, and while a lot of them can’t be fixed overnight, many of them can be sorted effectively.

Let’s wait and see what happens with the development of Flibanserin. I’ll keep you updated on it, and I’ll be letting you know what other research on women and desire is coming out.

What made me start blogging?
Five years ago I sat down on a dark November evening and wrote my very first blog entry. It was a bit ranty. I’d been misquoted by a journalist and was anxious it would get me into hot water (again).

I didn’t have a game plan when I started blogging. My partner (who’s way more tech savvy than I am) thought it might be a good way of sharing ideas I was struggling to convey via the mainstream media (I was writing several advice columns in magazines at the time, as well as hosting a regular radio phone in for BBC Five Live).

I approached the blog as a form of therapy. I wanted to work with the media but was getting a lot of stick for it professionally (I’m an academic as well as a sex educator). Having a place to blog would allow me to correct any errors in reporting and disclose bad journalism. I even hoped it it might even let me bring evidence into sex/relationships reporting – and show it was possible to do so without things becoming worthy or dull.

One thing I felt sure of early on was this blog was something I enjoyed writing, but I wanted to be useful, and most importantly to deliver things about sex, relationships, science and journalism that readers wanted to know about. Which is why the blog has always been shaped by things you’ve asked for.

Readers make this blog (or “why don’t you have comments?”)
Last summer I asked regular readers to give me feedback on this blog and got some very helpful responses. It’s taken me a while to implement some of these, but I have now upgraded the blog to include the things you asked for – photos and images to liven things up, a better blogroll, summaries at the start of most entries so you can decide if you wish to read on. And categories. Something I didn’ think about five years ago and really wish I had. I’m now in the process of going back through all the 800+ posts and adding categories to them, which I hope will make this blog a lot more useful to you.

The one thing this blog doesn’t have is comments. I did start off having them, but encountered several problems. As I was offering advice within columns and websites elsewhere I hadn’t planned to also answer problems on this blog. However, not all readers understood this so I frequently found requests for advice on anything from infidelity to penis size included in discussions about blogs relating to research design or journalism ethics. This sometimes led to some readers mocking those asking for advice, which of course is completely unacceptable for me as an educator.

Moreover, I’ve always blogged openly – never behind a pseudonym. I work within the community on sex/relationships projects and educational activities (in the UK and internationally). This meant I was very accessible, and felt vulnerable when those whose comments were deleted or not posted, made very personal threats.

I found moderating the comments was time consuming and took me away from other educational activities which I felt were more worthwhile. So I decided to remove the comments option. When I’ve asked readers if they want them back the general response is ‘no’. That’s mostly from people who feel the blog’s a safe space to get information which they can use as they wish elsewhere.

Of course I strongly welcome respectful email feedback and am always happy to add information or correct errors within the blog. You’re always welcome to start discussions on other forums or your own blog about issues raised here. For now I’ve no plans to reinstate comments, but since I’m occasionally asked why I don’t have them I thought this was a good a time as any to clarify the issue.

Achievements so far
Having read back to 2004 I’m pretty pleased with this little blog. It’s nice to see it’s grown into a resource that people trust and enjoy reading.

The things I’m most proud to have written are activist blogs that highlight medicalisation, exploitation and abuse. These include the debates around female sexual dysfunction, questioning high street stores stocking ‘herbal’ erectile dysfunction drugs (not approved by the FDA), exposing the Advanced Medical Institute’s aggressive sales technique for men affected by premature ejaculation, or highlighting misleading media coverage of the availability of Viagra on the high street.

I initially planned to use the blog to set right bad sex coverage in the media (or occasions where I’d been misquoted). This has been a theme within the blog although I think it’s become more focused over time (although not necessarily less ranty than my very first post). I can’t say whether it’s made much difference to journalists, and I hope it’s not put people off working with the media. I’ve found it helpful to describe poor practice – not least because the general trend for ‘experts’ working with the media is to act grateful for any exposure, not publicly discuss poor experiences or document bad practice. Gems for me include an expose of GMTV sending a cab to my home at 6am on the off chance I might wake up and come to their studio. Or how a TV show wanted to discuss female sexual confidence without mentioning genitals or masturbation. Or some rather nasty experiences with snotty TV producers just after I’d had a baby. Not to mention the hilarious case of the science journalist who really took a dislike to me (and colleagues). Oh, and let’s not forget the journalist who wanted me to recommend them an ‘unethical psychologist’ .

Of course, the past five years have not been spent simply slagging off journalists. No. Sometimes I’ve also turned my gaze to bad science too. Where it’s been depressing to report on a carnival of studies which seem to set us back sexually. Studies complaining women orgasm too easily, or there’s a ‘clitorocentric conspiracy’ against the vagina, how sex with a partner is 400% better than any other kind of sex you might have, and you can tell whether a woman has vaginal orgasms by her walk.

Let’s not forget my other bugbears. The fake formula and shonky surveys and my goodness this blog’s a treasure chest for those. And if I’m not being irritated by that, then there’s always the problem of psychologists talking about celebrities, or the general ethical issues raised by Big Brother for me to moan about.

Of course, it’s not all been bad news. Anyone would think this blog is only about gripes and grumbles. I’ve always wanted to showcase a variety of sexual experiences within this blog and not just think about sex just for a Western audience. I’ll continue to discuss issues relating to sex and seniors; teenagers; disability; transsexuality; lesbian, gay and bi issues; open relationships; BDSM; sexual health; contraception; prostitution; pornography; reproductive health; pleasure; desire; asexuality; dating; psychosexual problems; showcasing great sex pioneers; talking about safer sex; and as many other topics as I can find for you to read about.

Where to next?
Unlike five years ago, I’m now thinking strategically about this blog – who it’s for, what it does, and seeking to find ways to assess any impact it may have. I’ve noticed over the years it sometimes deviates into areas that interest me, but may not appeal to all readers. So my aim is to ensure the focus of the blog remains around the core things you’re most interested in when you visit – sex, science, and media.

I’m currently involved in overhauling the site so in the new year I hope to have far more open access materials available for you – relationships and sex guides, information about sexual and reproductive health, more advice and links to sources of help, along with practical information for journalists, healthcare professionals, parents, teens and teachers.

I’ve been asked by many readers for more information about how to become an agony aunt/media sex educator, so I’ll be blogging about this – as well as how to write a sex blog – in the not too distant future.

I’ll also be making use of twitter soon, as sometimes I blog about issues people need to hear about fast (particularly developments in science/health), so hopefully that will make messages more accessible. I’ll let you know once I’ve sorted it.

Obviously I’d like to hear what you’d like to see. How would you like this blog to develop over the next year (or five!). Are there any particular things you’d like to see more/less of? Topics you want covered? People you’d like me to interview for the ‘quickies’ section of the blog? Campaigns you want covered? Let me know what your vision is for this blog.

So, happy fifth birthday blog. Big birthday kisses to those of you who’ve been with me from the beginning. For those of you who’ve only recently found this blog I hope you like it enough to stick around for the next half decade. I notice one of my favourite other blogs Mind Hacks has also celebrated it’s fifth birthday too, so congratulations to them.

Time to blow out the candles and make a wish. Of course, I can’t tell you what it is. You’ll have to come back in five years to find out if it’s come true.

Brief background – female sexual dysfunction

Over the past 10 years the race has been on with pharmaceutical companies to find the ‘female Viagra’ – a drug to treat female sexual dysfunction (FSD).

At the same time, concern has been growing within healthcare, therapy and education about the medicalisation of sexual functioning. FSD in particular is a diagnosis with a controversial heritage, with concerns expressed that common (but often upsetting) female problems around lack of desire and difficulty experiencing orgasm have been repackaged within a illness-based model.

[You might also find this discussion held a couple of years ago on Woman's Hour that addressed FSD useful (includes links to support organisations relating to sexual difficulties). Plus this special issue of the journal Sexualities tackles the problem of medicalising sex for women and men, and Liz Canner's amazing documentary Orgasm Inc provides a thorough backdrop to the topic]

Over the years several drugs have been developed, although many did not get past early trial stages. Of those that did, testosterone patch Intrinsa was heralded as being the answer to lack of sexual desire in women, although was later found not to be clinically effective (and was never approved for use in the US). Another drug – PT141 – aimed at boosting desire (and aimed at men and women) also failed to meet safety standards and wasn’t developed further (although that wasn’t before the media promoted it as the sex wonder-drug of the future). Alongside these promised medications there’s been a whole slew of herbal products and ‘super foods’ (usually fruits, seeds and berries) promoted in the media and all guaranteed to boost desire or enhance orgasms.

Latest trials – Flibanserin
Flibanserin is a centrally acting anti-depressant type drug made by Boehringer-Ingelheim who have been developing it over the past few years. It is aimed at a condition referred to as Hypoactive Sexual Desire Disorder (HSDD) – or a lack of/no desire for sex in lay terms. Reports suggest the latest trials of the drug are about to be announced, and it’s likely the product will be promoted for public use within the six to eighteen months (pending FDA and EMEA approval). Early trials claim the drug boosts sexual desire, but (as with other SSRIs) this drug must be taken every day for 3-6 weeks before any effects will be noticed and continuously thereafter.

What’s interesting about this drug is it indicates a shift around how we conceptualise and ‘cure’ female sexual problems. Previously the message from drug companies was FSD was a hormonal problem and could be managed with additional testosterone. Flibanserin reframes FSD as a ‘desire is in your head’ model, working on neurotransmitters to increase libido. Moreover, previous drugs tended to focus on women who were approaching or had gone through the menopause (naturally or surgically). Flibanserin is being targeted at all women (so a far larger market share than products just for post menopausal women).

Aside from the wider worries about medicalising female sexual problems (which are caused by numerous factors), critics of Flibanserin question how an antidepressant can boost desire given a common side effect of such drugs are to reduce desire. There are also worries from healthcare workers and therapists around the long term safety of using such drugs and potential problems with withdrawal.

Those defending Flibanserin (and drugs like it) argue that therapists are only criticising the products as they want to promote talking cures over medical ones (and thus have a conflict of interest). They also have reappropriated feminist discourse to talk about women being left out or needing the same access to sex drugs as men (although the products available for men are actually limited and mostly only for erectile dysfunction).

The difficulty with discussing this area is that women do experience sexual problems for a variety of reasons. Many of these can be helped with education, better contraception, improving (or leaving) a difficult relationship, therapy, addressing psychological or physical health problems, or better sexual communication between a woman and her partner. These issues should be tackled as a first port of call, rather than recommending a pill or patch. However, given the embarrassment women experience over sex problems, plus additional pressures from the media and partners to be good in bed (and a desire for pleasure and intimacy), it’s easy to see why someone would prefer a magic bullet than having to work through what’s causing their problems.

Sadly drug companies (and practitioners allied to them) exploit this by making out anyone who questions the FSD diagnosis is anti-women or out to stop women enjoying sex.

What you can expect from media coverage
At each stage of development Flibanserin has already been promoted via the media as a forthcoming drug that will transform women’s sex lives. No doubt coverage over latest research on the drug will follow this format. It’s a dream for health writers and particularly glossy men and women’s magazines as you can discuss sex (and the stereotypical ‘women don’t like it’ angle) with a mix of science and the promise women who’re not sexy enough can be fixed.

You can expect plenty of headlines promoting a wonder drug to boost sex – and reinforcing the idea that women’s sex problems are ‘all in her head’.

What you won’t see is questioning about the drug, safety and long term effects. Nor will you see any critical reflection on the construction of FSD as a medical condition, nor any practical advice on the many reasons women may not experience the sex life they expect – and what they might do about this.

What journalists probably don’t know – behind the scenes of marketing Flibanserin
While Flibanserin has been developed, there has also been a systematic approach from Boehringer-Ingelheim to promote the product before it has been developed. In 2008/9 I’ve had two invitations to attend two two-day long ‘training days’ at top London hotels (with an honorarium of £1000 per session). This invitation has been extended to other practitioners within sexual health.

My understanding of the aim of these events were to highlight FSD (or more specifically Hypoactive Sexual Desire Disorder) as a problem and inform practitioners about treatment approaches. From that, key advisors who’d attended training days could speak further and influence colleagues to also promote FSD as a problem and recommend future treatments as they came on board. Here’s a copy of the agenda for one of the events to give you an idea about what was covered.

I did not attend these events. However, this did not prevent Boehringer-Ingelheim from trying to engage me in other ways. On 1 April this year I was sent an unsolicited invitation to write a paper for their journal British Journal of Sexual Medicine. You’ll see from both the letter and instructions for writing the paper that they had clear instructions about what they wanted me to say and how this would set the scene that HSDD was a prevalent and distressing problem doctors ought to be aware of – presumably so they could be alerted to a problem and be more willing to prescribe a pill when said medication became available.

This may not seem like a major issue, but it’s worth noting that such activity is frowned upon by reputable academics as really all you are doing is marketing a product, not engaging in true peer reviewed science. So obviously I didn’t accept this offer either.

[Since writing this Boehringer Ingelheim's Medical and Scientific Affairs Manager contacted me and requested a right to reply. You can read their response here].

I’m raising this here as journalists and the public need to know this may be considered a case where the market for the product is being worked upon at the same time the product is being developed.

Nobody is denying women have problems, but there are many ways to approach these without slapping a clinical diagnosis on women who don’t feel sexy.

Questions you should be asking about FSD and sex drugs
If you’re a journalist, healthcare provider or member of the public you should think about what may cause women’s problems with sex and solutions to those. Question whether a clinical intervention is the best option, and research how the category of FSD (and related diagnoses like HSDD) have been created (and who by). In particular you should ask the question whether taking SSRIs on a long term basis is the best answer to women who aren’t feeling desire.

Update 16/11/09
The press release for Flibanserin is now available. If you’re a journalist covering this story you may want to ask questions about efficacy, safety and medicalisation (as outlined above). You may also want the drug company to clarify exactly how many ‘satisfying sexual events’ (their term) were classed as significant as compared with placebo. The press release states a significance, but in lay terms how much more satisfying sex per month can a woman expect if she’s taking her daily dose of Flibanserin?

Update 17/11/09
Cory Silverberg has a clear and thoughtful analysis of the Flibanserin studies, reflecting particularly on how sexual experiences were measured. This blog highlights how Flibanserin is still an experimental drug (not quite how the media are reporting it). Also, it’s worth noting from Cory’s appraisal of the research how not all women in the study did experience significantly better ‘satisfying sexual events’ compared with placebo. Well worth a read for an appraisal of both the research and marketing approaches from Boehringer-Ingelheim.

Also, Neuroskeptic has a fantastic blog that tackles in depth the trials for Flibanserin and the interpretation of the findings.