Female sexual desire has always been suspended on a tricky societal tightrope. In the past, it was something to be repressed and undiscussed. Violate these norms — or just appear to — and the consequences were grim. Today, for many women, the pendulum has swung in the other direction: Wanting and having a lot of sex is frequently portrayed as an integral part of leading a healthy, balanced, modern life.

Despite these complex expectations, female sexuality remains under-researched and little-understood. This extends to common sexual issues, including a drop-off or complete disappearance of sexual desire, which most women experience at some point in their lives, says Anne Katz, PhD, a sexuality counselor and the author of Breaking the Silence on Cancer and Sexuality. Pinning down a singular cause can be difficult, because there are so many potential factors, everything from daily stressors, to major life changes like giving birth or grieving, to work or parenting stress, to health conditions like insomnia, depression, anxiety, to side effects from a long list of drugs, including birth control and allergy medications. Ageing, and the shifts in hormone levels that come with it, can play a significant role too, as can relationship dynamics. According to Bat Sheva Marcus, PhD, a sex therapist and the author of Sex Points: Reclaim Your Sex Life with the Revolutionary Point System, desire issues are common for women in long-term relationships, even healthy, happy ones. “They feel like there is something wrong with them,” she says.

When you consider all the potential culprits, of course a lowered or vanished libido is one of the most common sexual issues women experience. And yet, to this day, there aren’t great medical options for women who are experiencing it.

The Little Blue Pill

Erectile dysfunction, the most common sexual disorder among men, has long had a vehicle for discussion and treatment: Viagra. Approved by the FDA in 1988, Viagra isn’t a libido drug — it acts on the circulatory system (rather than the brain), directing blood to the penis. But the result when it was introduced was essentially the same: Millions of men who weren’t able to have sex suddenly were. Unsurprisingly, the drug was a massive hit: Within a year of its launch, sales exceeded $1 billion.

The launch of “the little blue pill” was a bona fide moneymaker — it was time to get to work on a pink equivalent for women. What could go wrong?

Viagra’s immediate blockbuster status spotlighted long-existing gender discrepancies within sexual health, an inequity baked into the broader medical system. Men have long been the default gender for clinical research, resulting in a far better understanding of the conditions and symptoms that affect them.

Following Viagra’s launch, a group of researchers set out to level the playing field, an initiative that took on increased urgency given the drug’s ripple effects. “You saw all these women coming in saying, ‘My husband is on Viagra, he wants to have sex all the time, I have no interest,” said Leah Millheiser, MD, a clinical assistant professor and director of the female sexual medicine program at Stanford University School of Medicine. “A core group of doctors took notice and said: ‘We need to do something about this, we need to understand this better, we need treatments for these women.’”

Pharma took notice, too. The launch of “the little blue pill” was a bona fide moneymaker — it was time to get to work on a pink equivalent for women. What could go wrong?

A Different Prescription

Unlike men, women can physically have sex without being aroused. And so pharma targeted a related-but-separate condition: Hypoactive Sexual Desire Disorder (HSDD), defined as low or absent sexual desire that persists for at least six months and causes personal distress. Added to the DSM-III in 1987, HSDD took a common, if amorphous, issue and turned it into an explicit condition pharma could try and treat.

One of the first courses of action was to test Viagra on women to see if it worked on libido issues, in addition to directing blood to the penis. It did not. A number of additional candidates were explored, including testosterone patches and creams, none of which did much.

Enter flibanserin. Initially developed by Boehringer Ingelheim as an antidepressant, the pharma company shifted its focus to using the drug to treat HSDD. In 2010, the drug was rejected by the FDA, which cited its marginal efficacy and potentially serious side effects. Boehringer Ingelheim halted production and sold the rights to the drug to Sprout Pharmaceuticals, a pharma company later acquired by Valeant.

Under new ownership, flibanserin was again rejected by the FDA in 2013. Two years later, following an intense public relations campaign marketed as a grassroots effort, it finally received the greenlight, launching as a daily pale pink pill called Addyi.

There is the complex web of societal expectations placed on women’s sexuality that dictate what constitutes “normal” — and by extension, what needs to be fixed.

But very quickly, it was clear Addyi — and, by extension, Vyleesi, a competitor that launched in 2019 — wasn’t the magic bullet women had been hoping for. Whereas Viagra could be taken on-demand, Addyi had to be taken every day. What’s more, it came with serious potential side effects, including low blood pressure, fainting, and nausea, and couldn’t be taken with alcohol. Most damningly, however, was its lackluster efficacy. Viagra allowed men to successfully have intercourse 69% of the time compared to 28% with a placebo. In clinical trials, women receiving Addyi reported an increase of 0.5 “satisfying sexual events’’ a month; Vyleesi didn’t fare much better; 25% of women reported an increase in desire, versus 17% of those in the control group.

In the end, Addyi prescriptions never took off, and last year the maker of Vyleesi announced it would divest the drug due to tepid demand. Overall, sales have been dismal-to-non-existent. For most women struggling with a decreased or absent sex drive, available HSDD drugs simply haven’t been the answer.

What’s more, the question of whether it’s even possible to medically manufacture female sexual desire remains up for debate. While theoretical models suggest Addyi and Vyleesi modulate serotonin and dopamine levels in the brain, their exact mechanisms are not well understood. “For the most part, Addyi works as a mixed serotonin antagonist,” says Sheryl Kingsberg, PhD, the division chief, behavioral medicine at University Hospitals Cleveland Medical Center. “It’s not an SSRI but works similarly, which is why it was originally tested as an SSRI.”

Adriane Fugh-Berman, MD, a professor of pharmacology at Georgetown University Medical Center, has a darker view of the situation. “The main effect of the two drugs that have been approved for low libido is sedation,” she says. “If you are unhappy with your sex life or distressed about your sex life and you take a sedative, you maybe might be less distressed about it, but that’s not really getting to the core issue.”

Advocacy or Advertising?

Women deserve so much more when it comes to sexual health, starting with a medical field that takes their sexuality and symptoms seriously; this includes more research and treatment options around persistent low libido.

But with Addyi, and HSDD more broadly, two flawed systems converged. On one hand, there is the pharma industry, which has a long, checkered history of pathologizing normal conditions and influencing prescribing patterns through unbranded campaigns designed to look like advocacy efforts. On the other, there is the complex web of societal expectations placed on women’s sexuality that dictate what constitutes “normal” — and by extension, what needs to be fixed.

While both systems often claim the advancement of women’s health as their lodestar, the reality doesn’t always match up. And in some cases, as with Addyi, a medical system can be used to create new expectations for women’s sexuality in the name of gender equality.

Take the drug’s launch in 2015, which came on the heels of a high-profile publicity push by Sprout, Addyi’s manufacturer. This included a campaign titled Find My Spark, which didn’t mention Addyi by name but promoted the prevalence and severity of HSDD, directing women to speak with their doctors about soon-to-be-available medical options. The campaign’s language and imagery focused on addressing gender inequalities within sexual health, but its primary target was to drive up demand for prescriptions.

HSDD isn’t a clean slate on which to project the fight for gender health parity. Pretty much everything about the condition… has been influenced by drug companies developing medications to treat it.

These goals can co-exist, but they shouldn’t be separated. A pharma company, despite its purported intentions, is not an advocate or a nonprofit but a corporation beholden to its shareholders. By extension, a brand-name drug, which exists to make money in addition to offering medical relief, is not a pure vehicle for addressing gender disparities within sexual health.

HSDD raises important issues, notably our lack of understanding and options for common female sexual dysfunction disorders. But as with Addyi, HSDD isn’t a clean slate on which to project the fight for gender health parity. Pretty much everything about the condition — its clinical definition, standard diagnostic criteria, and studies on its prevalence and impact — has been influenced by drug companies developing medications to treat it. (Nonprofit organizations that have become the authorities on HSDD, including the International Society for the Study of Women’s Sexual Health, have financial ties to pharma; meanwhile, many of the scientific experts who regularly speak to journalists about HSDD and the medications available to treat it have ongoing financial relationships with drug manufacturers.)

The result is a disorder that’s been molded by organizations and individuals with skin in the game of sorting people into those who are healthy, and those who might need medication. The disorder’s rise to prominence “really co-occurred with the testing and development of filibartherin,” Katz says. “If you have a hammer, everything’s a nail.”

But imposing clean lines on sexual desire, an often amorphous, malleable, multifactored thing, isn’t easy, or maybe even possible. To be diagnosed with HSDD, a woman must experience “distress” over the loss of sexual desire that is not caused by external factors such as cultural expectations around sexuality, comparisons to one’s peers, body image issues, a partner’s dissatisfaction, or pre-existing health conditions like depression or anxiety.

How does one go about determining what’s internal versus external? And distress, as a metric, is slippery — there are a dizzying number of ways to be a healthy woman and yet still be distressed about aspects of one’s health. I am a “healthy” weight, according to my BMI, but my weight sometimes still distresses me, despite my best efforts — a side effect of growing up in a culture that glorifies thinness at the expense of all kinds of things, actual health included.

For Lux Alptraum, a freelance writer and the author of Faking It: The Lies Women Tell about Sex — And the Truths They Reveal, separating sexual desire from the expectations of interpersonal relations and societal norms has proven a fantasy. This has become increasingly apparent to her with age; in her teens and 20s, Alptraum’s relationship to sex and sexuality was heavily influenced by internalized messages that wanting and having a lot of sex was not just desirable, but healthy and right. “I think it’s very easy to ‘have’ a high libido when you have this voice telling you, ‘Your worth as a person is measured by how much sex you are having, and the more sex you are having, the better person you are, the more value you have,’” she says.

Imposing clean lines on sexual desire, an often amorphous, malleable, multifactored thing, isn’t easy, or maybe even possible.

One Step Forward, Two Steps Back

For many people, sexuality is a vital part of life. There is something fundamental about it, Marcus says. The act can represent “a letting go that you don’t do often with a lot of different people — it hits a core part of our being I think in a way that almost nothing else does… it changes the tenor of the relationship.” Desire issues are real, and they can be impactful, to the point of stressing and even breaking relationships, something she has seen within her own practice.

Despite Addyi and Vyleesi’s muted response, there are a number of potential candidates in the pipeline for female sexual desire and arousal problems, including Lybrido and Lybridos, which are being developed by a pharma company based in the Netherlands. Essentially a combination of Viagra and testosterone, the former is intended to produce a physiological response in addition to a psychological one by directing blood to the vagina to spur engorgement and arousal. Libradose, meanwhile, is designed to reduce inhibition mechanisms in the frontal cortex. Ovoca, an Irish company, is testing a nasal-spray for HSDD, while Kingsberg is involved in clinical trials for topical sildenafil, or Viagra, for women with arousal issues.

Addressing disparities within sexual health will require more than better drugs, Fugh-Berman says: “We often look to pills for things that used to be dealt with in a non-pharmacological way.” Sex education, which has long prioritized the male sexual experience (even at my all-girls high school) is a good place to start, as is developing a more robust, accessible discourse around the mechanisms of female arousal and orgasm. Under this lens, the attention Addyi (and later, Vyleesi) generated doesn’t feel like a clear-cut win, particularly when you consider its efficacy and side effects. If it feels like progress at all, it’s the two steps forward one step back kind. Yes, we should be talking more about issues regarding low libido, sexual desire, and arousal in women. And yes, women deserve more options for, and a better understanding of, these conditions. But having this conversation spearheaded and marketed by drug companies with products to sell, using the language of feminism to advertise drugs that don’t work well and come with serious side effects, feels like a simplification and a distraction as much as a victory.