The most common sexual problem among women is a lack of desire. Since ancient times, people have formulated mysterious potions and herbal remedies to increase sexual passion, and today there are drugs and treatments available. However, is a lack of desire a medical problem or a social outcome? Perhaps a lack of desire results from a psychological state or from sexual and interpersonal dynamics between the partners. Additionally, why is a lack of desire specifically prevalent among women? These two questions may be related, and I will explain. I'm going to start with 'psychological' reasons, and then move to biological reasons which are the foundation for the pink-pill. Social norms that reduce desire only in women How much can a woman express sexual desire in a society where female sexuality is considered slutty? how much sexual desire will a woman have if she has grown up with messages that her sexuality is dangerous for her and for others and therefore she must cover herself? In some religious traditions she can't even sing near men. The answer is clear. A depressed psychological state reduces desire, it appears reasonable and intuitive that a woman suffering from depression would have a lower sexual desire. Indeed, research indicates that depression increases the likelihood of a woman to also have reduced desire. It's difficult to distinguish causality here, that is, whether depression leads to a decrease in desire or if the decrease in desire leads to depression. Statistical tools help researchers here, and the answer is... both. Depression raises the risk of not having sexual-desire, and not having sexual-desire increases the likelihood of depression (1). If women are more susceptible to depression to begin with (why is that?) that might be part of the answer.
Unfortunately, as we will see later in this post, a side effect of treatment with antidepressant medication is often a significant decrease in sexual desire. Therefore both depression and the treatment for depression reduce desire which complicates the therapy. There are drug-solutions, but I won't delve into them this time. The couple's dynamics may reduce desire, How much desire can be expected from a woman who engages in sex out of obligation? How much desire will be present in relationships without a sense of security, without responsiveness to emotional needs, and without satisfying sexuality? ~~~~~~ For those who like it deeper, I'm adding here a general discussion on the psychology of desire: the idea that problems with sexual desire stem from the dynamics of the couple is supported by research by Professor Birnbaum (2,3). She argues that generally, for both men and women, desire is a barometer for the internal belief of "how much the other person can be a supportive figure for me." What is meant by a supportive figure? A supportive (attachment) figure is a concept from a central theory in psychology called attachment theory, which I wrote about here. In short, a supportive figure provides us with security in times of stress, and that security allows for sexuality and overall exploration of the world. In other words, sexual desire results from the internal belief that the other person will provide us with security. For each individual, different things in their partner will contribute to their sense of security, such as physical strength, status, beauty, emotional intelligence, tenderness, and so on, depending on each person's inner world. At the beginning of a relationship, we guess based on our gut feeling that the other person is suitable to be our attachment figure and we have no information that contradicts this belief (since we don't know each other yet) and the desire is therefore very strong. Many times we guess wrong, and then we feel disappointed and hurt by the loss of the imagined attachment figure . However, when we guess correctly, a relationship develops.
Over time, we get used to each other and the sex is taken for granted, in addition familiarity reduces the mystery that can arouse desire, and - in the context of the former section - we also discover the flaws of our partner as an attachment figure. Taken together, in a long-term relationship the passion allegedly decreases. However, the friendship that develops covers this up and maintains the relationship. Friendship implies, among other things, support and security. That is, in spite of the flaws, the internal belief that the partner is a supportive figure and that the relations provide security remains intact. So does desire really disappear? In fact, in a stable and friendly relationship, desire only appears to decrease, and during a couple crisis, desire will reappear to reconnect the couple. Because the internal belief that our partner serves as a supportive figure still exists, what is called make-up sex. Therefore, in a couple's relationship where there is no support during stressful times, the internal belief that the other person is a supportive figure slowly diminishes, and the relationship deteriorates. Early learning may cause adults to desire those who are synchronized with us. Our first support figure is the mother, and one of the prominent things in the parent-child relationship is the creation of synchronization: we start to talk like children, repeating each other, mimicking and more. Synchronization helps to communicate at stages where there is still no language. Likewise at the beginning of a romantic relationship, we create synchronization. We enjoy discovering - and emphasize - the points of similarity "I also love .., I also do ..". Beyond conscious and intentional synchronization, there are many findings that support the idea that when we say we have chemistry with someone, we actually experience physical synchronization: body language, breathing, skin conductivity, sweating, excitement, and even synchronization in hormone release and brain activity. This is a fascinating topic that I'm addressing here. The idea is that the same mechanism of synchronization that created the parent-child relationship creates the initial attraction between romantic partners and in both cases may serve to identify the attachment figure. I suggest the hypothesis that the infant learns to link synchronization to security or to a support figure, and therefore as adults, we are attracted and feel desire to those who synchronize with us. More on that is here. ~~~~~~ I will now address the elephant in the room: why is lack of desire more common in women than in men? after that, I'll write about the brain mechanisms of desire and the translation of the knowledge into medication. Do women have less desire to begin with? The common cliché says that in order to have sex, women need to love, while men... need a place. Is this true? Indeed, studies show that women report less desire than men (6) and social evidences support this: the majority of consumers of prostitution are men, more priests break their vow of celibacy than nuns, gay men have more sexual relationships, on average, than heterosexual couples, and lesbian couples have the least. But the question is whether the difference in sexual passion is innate or acquired. In fact, in humans, this cannot be answered. All differences can be the result of social norms, upbringing, personal security, and so on. So, in humans, the question remains open In the picture: a statue at Burning man. In the explanation it was written: "if only women could feel safe". In other words, it's our culture that suppresses expression of sexual desire in women. Picture by Amos Gdalyahu.
It is ideal to test if the difference in desire between men and women is innate or acquired in animals, where there are no cultural norms. To the best of my knowledge, no research has been done to answer this question directly. There is indirect evidence though supporting the notion that males have a higher sexual desire, for example: female rats with unenjoyable sex lose interest in sex, while males with unenjoyable sex continue to want it. However, this is still not enough to determine and there is no consensus on the subject.
On the background of our biology, the social and relational impacts I previously explained, as well as negative sexual experiences, can reduce future desire. This happens through changes in the brain. In addition the brain is affected by internal bodily processes (such as age or day along the menstrual cycle) or as a side effect of medications. Understanding the biological basis of desire allows translating the knowledge into medications to increase desire.
Continuing on, I will review existing medications and future developments. While doing so I'll explain brain mechanisms and will address the fundamental question (which is the subject of a heated emotional debate) of whether it is legitimate to treat desire problems with medication - the "pink pill" (7).
Pharmaceutical companies became interested in the subject of sexuality after the success of Viagra. Viagra itself was not developed to solve a sexual problem, but rather to solve migraine and high blood pressure by relaxing the muscles that surround the blood vessels. It failed as a solution to high blood pressure and migraine. However, as an unexpected side effect, it was found to cause erections even in men with erectile dysfunction. With some persuasion, Pfizer turned the bug into a feature, and thus Viagra was born in 1998. The greatness of Viagra is that it only increases blood flow to the sexual organ during sexual stimulation.
(I wrote a post on erection, the unforgettable show of Dr. Brindely and the development of Viagra here).
What about Viagra for women? Indeed, Viagra increases blood flow to the genitals when sexually stimulated. But increasing sexual desire is a completely different matter from increasing blood flow to the vagina, which Viagra is not supposed to do, even in men. While men who take Viagra feel the erection during sexual stimulation and this can further arouse them, most women do not feel the effects of Viagra. Pfizer explored the possibility of using Viagra to increase desire in women, but as expected, it did not succeed. However, the commercial success started the race to find the "pink pill" (7). In 2004, Procter & Gamble obtained approval from the U.S. FDA for the first solution to increase sexual desire in women, Intrinsa. It was a patch that women applied to their skin and released testosterone into their bodies. In clinical trials, the patch did alleviate the suffering of women with desire problems, increased their sexual arousal, desire, and pleasure from orgasm. The debate over the approval of the patch for use was fraught between the medical establishment (the pharmaceutical companies and doctors - a group dominated by men) and a feminist group called The New View, who strongly opposed the idea of pharmacological treatment for increasing desire in women. This group was primarily made up of psychologists, social workers, and sociologists - a group dominated by women. Thus, what could have been an issue for women's benefit became a political battle charged between groups with a history of animosity: men versus women, social sciences versus exact sciences. The FDA did not approve the drug for use in the US. However, in 2006, the drug was approved in Europe but only for women who suffered from lack of sexual desire due to surgery to remove the ovaries and under strict supervision due to the fear of testosterone abuse for illegal muscle building. In the end, under these conditions, the marketing of the drug was not profitable, and Procter & Gamble discontinued it in 2010. Nevertheless, such patches can still be obtained, and estimates suggest (7) that every year in the US, millions of women (!) obtain and use off-label testosterone-releasing patches! Until today, it is not exactly known how testosterone causes an increase in sexual desire (in both men and women). It is known that the area in the brain responsible for desire is activated by a substance called dopamine, and that testosterone causes the release of dopamine in this center and also creates more receptors for dopamine in the desire center. Artificially activating the desire center causes an explosive desire (see post here).
Apart from testosterone, there are other substances that activate nerve cells in the sexual passion center, while there are others that dampen the passion center. One of the substances that dampens the desire center is serotonin. Indeed, anti-depressant drugs that increase serotonin (SSRI) can cause sexual desire problems and difficulty achieving orgasm. However, this bug can also be turned into a feature: intentionally raising serotonin to delay desire and prevent premature ejaculation (which is done by the drug Priligy).
Taken together, the desire is the ratio between inhibition and activation of the desire center. Therefore, another way to increase desire is to lower the level of the substance that inhibits the desire center, which is serotonin (This an opposite opposite effect to the effect of anti-depressant SSRI drugs). Indeed, a German company developed a drug for female sexual desire called Flibanserin (Addyi) which does exactly that: it reduces the amount of serotonin in the brain and thereby reduces the brakes on desire. The drug received approval (on 2010) and it succeeds in increasing desire, but the average effect is not high. This approval was all but easy. Again, there was a heated debate between the drug company and The New View women's group. Facing the suffering of women who experience loss of desire, The New View supporters argued that in menopause, this is a natural process and women should accept the changes of age. In addition, they argued that female sexuality is holistic and it is not logical that a pill could increase desire. They claimed that the problem lies in the social, couple, or personal context, and that counseling would be more appropriate. They felt destiny to rescue women from taking a pill that may cause them desire but within toxic relationship, or as a bypass to overcome personal and inter-personal problems, or simply would waste their money. They organized campaigns that portrayed pharmaceutical companies as creating a medical problem (low desire) when there's none so they could treat it with their drugs. They also portrayed doctors as corrupt, receiving money from pharmaceutical companies. Note that, The New View's women can also be accused in a similar way that many of them give expensive therapy sessions and their assessment of the success of their treatment is usually subjective. While the emotional debate was on going, the FDA wanted to test if the drug was indeed effective in increasing desire. For this, the FDA demanded from the developing company a measure that was previously used to measure the effectiveness of Viagra, even though the only thing shared by the two drugs is their involvement in sexuality. The measure was the number of times in a month that a woman engaged in satisfying sexual activity. However, an increase in desire does not necessarily translate to more sexual activity, let alone satisfying sexual activity. As expected, the results of this measure were not impressive. Therefore, despite the company investing about $2 billion in drug development, the FDA did not approve its use.
Even after additional clinical trials were conducted on thousands of women that demonstrated the drug's effectiveness, the FDA still did not approve it. In the end, the drug company launched a joint campaign with women's organizations that accused the FDA of discrimination against women since all the drugs approved in the field of sexuality until then were for men. So, only after a long journey that combined medical claims with social claims, the drug was approved and marketed under the name Addyi in 2016 but... with strict limitations due to safety concerns, and only doctors with a special license could prescribe it. It was difficult to obtain the drug and sales were poor. In 2019, the safety concerns were removed but the drug still failed commercially.
Another drug for increasing desire, Vyleesi - the second and last one approved for use by the FDA - activates the center of desire in the brain, unlike the previous drug that reduces inhibition. It is administered by injection, as opposed to Addyi which is given in a pill form, but it has an advantage: it is not taken regularly but only when one wants to increase desire. However, this drug also did not succeed economically: its average effect was relatively small, and its marketing was also minimal, perhaps because it entered the market just before the COVID-19 pandemic.
How to improve medications for elevation sexual desire?
Overall, the medications for increasing sexual passion have received a negative reputation of "not very effective." However, this is true only on average. For some women, the medications work very well. The current direction of development is that different women with a problem of low desire suffer from different problems and it is not right to give them all the same treatment: for some women, the problem of low desire arises from an excess of inhibition of desire (like excess serotonin), while in other women, the lack of desire arises from decreased activity of the system that stimulates desire. Amazingly, it seems possible to determine from a genetic test to which group the woman belongs! (8).
The idea is to give the medication that reduces inhibition to women who have too strong of an inhibition, and the medication that stimulates the desire system to women who are less sensitive to sexual stimuli. This is personalized medicine.
Why not give women both? In other words, to reduce inhibition of desire and to increase the system that activates desire? It is thought that for some women, a negative sexual experience and social influences have caused an association between sexual stimulation and inhibition of desire, for example after a sexual assault. In these women, activation of the system that responds to sexual stimulation will bring about activation of the association that inhibits desire. These women do not need a stronger response to sexual stimulation, but rather a reduction in inhibition. The average results of personalized medicine treatment are about three times better than the results with the latest drug developed, Vyleesi. This is the direction of future development (9).
In summary, the pink pill is not yet here, but there is a promising direction. It should be noted that pharmacological treatment is tested against control group that receives a similar treatment in an double-blind manner. In contrast, it is very rare - if done at all - to compare talk therapy quantitatively to control. Usually, we rely on the therapists' evaluation of their success rates in treatment.
The dispute between supporters of the New View and the medical establishment is still ongoing, but in my opinion, as with depression treatment, the best way is integration: both of them together. Environmental factors (relationship dynamics, life experience, social norms, etc.) caused a change in the brain, which both conversations and medications are trying to change. It is not easy to create lasting change in the brain, and it is advisable to use all the tools available to us. A pill or injection can cause change, but when the social or personal beliefs still limit the blossoming of desire, the effect of the treatment may quickly wane. On the other hand, talk therapy sometimes needs chemical augmentation to give it the strength to create a lasting change in deep patterns. In my opinion, every therapeutic approach is legitimate, provided that the specific patient's benefit is the top priority, regardless of any agenda, ego, or money.
The birth control pill is considered the catalyst of the sexual revolution, as it allowed women for the first time to choose sex solely for pleasure and weakened the connection between sex and pregnancy. Viagra did not create a social revolution but its tremendous economic success indicates its importance. What will be the social impact of the pink pill? Will it cause women to give up on building desire from emotional intimacy and settle for a quick chemical fix? I don't think so. Will the pink pill cause women who have lost desire in a toxic or at least unsatisfying relationship to stay in it, since the pink pill will override their natural barometer? It could be. Like everything else, the pink pill can be used for good or bad. One thing is clear: loss of sexual desire can cause real suffering and those who suffer from it, who are usually women, need help. The translation of biological knowledge into drugs is focused on biology, but we operate in a holistic context that includes interpersonal relationships and many other parameters.
Beyond the translation of knowledge into drugs, I am simply fascinated by the workings of the sexual operating system. Every time I try to understand how the brain works, I stand in awe of its beauty, just as I stand in front of a cascading waterfall into a magical pool.
Bibliography
The International Society for the Study of Women's Sexual Health Process of Care for Management of Hypoactive Sexual Desire Disorder in Women. (2018), Anita Clayton, Irwin Goldstein, Noel Kim, Stanley Althof, Stephanie Faubion, Brooke, Parish, Sharon Faught, James Simon, Linda Vignozzi, Kristin Christiansen, Susan Davis, Murray Freedman, Mayo Clinic Proceedings
Evolved to be connected: the dynamics of attachment and sex over the course of romantic relationships, (2019) Gurit Birnbaum, Current Opinion in Psychology
The magnetism that holds us together: Sexuality and relationship maintenance across relationship development, Gurit Birnbaum, (2015).
Bio-behavioral synchrony is a potential mechanism for mate selection in humans, Scientific Reports, Shir Atzil, (2022).
Wireless multilateral devices for optogenetic studies of individual and social behaviors, Nature Neuroscience, John A, Rogers, (2021).
Sexual desire and sexual activity of men and women across their lifespans: Results from a representative German community survey, BJU International, Elmar Brähle, (2008).
Politics of Sexual Desire, Current Sexual Health Reports, James Pfaus, (2022).
A survival of the fittest strategy for the selection of genotypes by which drug responders and non-responders can be predicted in small groups (2021) PlosOne, Höhle D, van Rooij K, Bloemers J, Pfaus JG, Michiels F, Janssen P, Eric Claassen, Adriaan Tuiten.
Efficacy and Safety of On-Demand Use of 2 Treatments Designed for Different Etiologies of Female Sexual Interest/Arousal Disorder: 3 Randomized Clinical Trials, Journal of Sexual Medicine, James Pfaus, (2018). The current status of pharmaceutical development 10. https://www.pharmaceutical-technology.com/news/female-sexual-interest-drug-reaches-tipping-point-with-phase-iii-plans/?cf-view