When Tennessee mother of four Amanda Blackie Parrish got divorced, started dating, and eventually met Ben, life was good. He was "spectacular," she said, a Pierce Brosnan lookalike who loved her kids, showered her with affection, and was attentive in bed. He had children too, so their time together was mostly spent on weekends full of dinners and talks and intimacy both physical and emotional.
Then one day a few years into the relationship, Parrish's sexual desire just stopped. "It was like a light switch going off," she said.
They would still go to dinner, but Parrish would try to prolong it so they would just go to bed when they got home. Sometimes, she'd try to make herself fall asleep, or fake sleep, so she wouldn't have to come up with an excuse for avoiding sex.
"It wasn't that we didn't have sex—we did—but it suddenly felt like it was more obligatory," Parrish, now 51, said. "Once I started, it wasn't an issue. It was getting me started. Gone were the days of me being excited and flirty and initiating—long gone."
That began to weigh on the relationship. Ben was patient and understanding, but he was hurt and wondering if he did something wrong. Parrish was frustrated and missed the intimacy that regular sex brought.
"I found myself at the end of our weekends not being satisfied and feeling sad," she said.
Parrish saw her doctor, who diagnosed her with hypoactive sexual desire disorder (HSDD) and helped connect her to a clinical trial for a new drug called flibanserin.
While flibanserin is billed as "Viagra for women," it affects the brain, not the body, claiming to increase some women's desire for sex but not treating a physical problem like lack of lubrication or difficulty orgasming. According to Dr. Sheryl Kingsberg, a professor of reproductive biology and psychology at Case Western Reserve University and a clinical psychologist who works with women suffering from sexual dysfunction and who worked on the flibanserin trials, flibanserin works on the brain's neurotransmitters, increasing dopamine and norepinephrine, which are related to sexual desire, and decreasing serotonin, too much of which can quash desire. That makes it unlike Viagra, which increases blood flow to the genitals but doesn't create a mental urge to have sex.
"In order for [drugs like Viagra] to work, men must have desire," Dr. Kingsberg said. "If they just take a pill and sit there and work on their taxes, they aren't going to get an erection. Unless they're turned on by taxes."
Viagra, Cialis, and similar drugs have been good news for men with erectile dysfunction and big money for pharmaceutical companies. Viagra alone has made the drug company Pfizer $1.8 billion in international sales. But for many women with sexual dysfunction, the issue is psychological, not physical. "The most prevalent problem is in the brain, and it's about wanting sex," Dr. Kingsberg said.
An estimated 16 million women over the age of 50 suffer from some form of female sexual dysfunction, and researchers hoped that for many of them, flibanserin could be a treatment option. While women who report sexual dysfunction are more likely to be menopausal or post-menopausal, in one large-scale study, about 10 percent of women reporting a distressing sexual problem were under the age of 45.
Parrish started the trial in 2009, and didn't know if she was given flibanserin or a placebo. A few weeks in, though, she noticed changes.
"I was driving down the road during lunch and texted Ben," Parrish said. "He texted back and I felt a flutter, and it wasn't my heart skipping a beat—it was down further south. And it was like, Oh my god, I think I'm getting horny!"
Over the next few months, their sex life improved dramatically.
"It was a truly magical experience," Parrish said. "That sounds so cheesy, but it was like a whole different world opened up for us, and that took us to a new level of intimacy that we had never had before. Dialogue started about things I might like that I'd never expressed to him, and things he might like that he'd never expressed to me, not because we didn't trust each other but because the conversation had just never started. Once I became more of an initiator, he relaxed."
Then, suddenly, it was over. The trial ended, and the FDA did not approve flibanserin.
Flibanserin has now submitted the drug to the FDA three times, most recently this month. The previous two submissions were rejected, with the FDA saying it wasn't clear that the drug worked well enough, especially when it comes to "satisfying sexual events." But, Dr. Kingsberg said, the FDA should be looking at desire for sex, not just the outcome of it.
"There was significant improvement, but not great, in satisfying sexual events," she said. "But it also showed significant improvement in desire and decrease in distress, which we all look for in showing resolution in a problem."
Flibanserin has been tested on 11,000 women over the course of several studies. Researchers found that subjects on both flibanserin and the placebo noted upticks in sexual desire, but that there was a statistically significant difference in sexual desire between the women on flibanserin and those on the placebo. The FDA also expressed concern about the side effects, which are mostly limited to nausea, fatigue, and dizziness. Advocates for flibanserin point out that no serious adverse side effects were reported in the trials. Viagra, which in 2005 was fast-tracked for approval and given the go-ahead in six months, can cause vision loss, deafness, heart attack, and even death. Xiaflex, which treats curvature of the penis and was approved by the FDA in 2013, can cause penile rupture.
The FDA has approved several drugs for male sexual dysfunction. There are currently no drugs on the market approved to treat HSDD.
"There's clearly a double standard," Dr. Kingsberg said.
But the FDA says no double standard exists.
"There are no FDA-approved drug therapies to treat disorders of sexual desire or orgasm for women or men," Andrea Fischer with the Office of Media Affairs for the FDA told Cosmopolitan.com in an email.
The FDA says the approved male sexual enhancement drugs treat either erectile dysfunction or "a condition that causes bothersome curvature of the penis," Fischer wrote. There are also testosterone therapies available for men, but those are only approved for men with low testosterone levels and none of them "are FDA-approved to specifically treat male sexual dysfunction," even if many men nonetheless use them for that purpose. And there are FDA-approved sexual drugs for women; those drugs treat pain during sexual intercourse and vaginal atrophy due to menopause. But none of these drugs treat HSDD for men or women.
Still, women's rights advocates say the approval of the many drugs for men shows that the FDA recognizes the importance of male sexual satisfaction, but doesn't put the same premium on women's sexual desires. And they are now taking up the charge. A new campaign called "Even the Score" states that "women have the right to make their own informed choices concerning their sexual health; that gender equality should be the standard in access to sexual dysfunction treatments; and that the approval of safe & effective treatments for low desire should be a priority for the FDA." Organizations in support of FDA approval of a drug treating female sexual dysfunction include the National Organization for Women, the Association of Reproductive Health Professionals, Black Women's Health Imperative, and the American College of Nurse Midwives.
Susan Scanlan, a veteran women's rights advocate and chair of "Even the Score," says the right to sexual desire is a feminist issue.
"Women had to fight to even be included in clinical trials," Scanlan said. "We had to fight to be recognized as having reproductive rights. If someone had told me 20 years ago that birth control would be under attack, I would have thought they were smoking the drapes, but here we are. We had to fight for our rights to be reproductive beings, and now we have to fight for the right to be sexual beings."
She says the FDA decision is more about sexism than good science. "I know inequity when I see it, and I'm telling you, this is gender inequity writ large," she said.
The FDA disagrees.
"For some time, the FDA has recognized the challenges involved with developing treatments for female sexual dysfunction," Fischer said via email, adding that the agency convened a two-day meeting last October to discuss the issue. "We are committed to working with companies to develop safe and effective treatments for female sexual dysfunction, as we do for all areas of unmet medical needs. The FDA's regulatory decision-making on any drug product is a science-based process that carefully weighs each drug in terms of its risks and benefits. The agency evaluates drugs based on science and strongly rejects claims of gender bias."
But it's not just the FDA voicing skepticism about the drug; some sex therapists and psychiatrists also oppose it. In an opinion editorial for the Los Angeles Times, NYU School of Medicine clinical associate professor of psychiatry Leonore Tiefer and University of Amsterdam professor of sexology Ellen Laan criticized the feminist push for flibanserin, saying a decrease in sexual desire reflects "a relationship problem" or "a normal aspect of life changes." Characterizing decreased libido as an unmet medical need, they said, was a crass move by the pharmaceutical industry to get FDA approval for a new billion-dollar cash cow, not a nod to women's sexual rights. According to Tiefer and Laan, "The drugs for women didn't work and were unsafe."
"Is lack of sexual desire a medical problem?" Tiefer asked Cosmopolitan.com. "Should there be a pharmacological treatment for something that isn't a medical problem? What's wrong with losing sexual desire?"
According to Tiefer, hypoactive sexual desire disorder isn't a real medical condition — she notes it is not in the Diagnostic and Statistical Manual of Mental Disorders (DSM) V, published by the American Psychological Association and which sets the standard language for mental disorders (HSDD was in the DSM IV, and the DSM V split it into two disorders, "male hypoactive sexual desire disorder" and "female sexual interest/arousal disorder").
"There's no damage, there's no harm, there's no medical consequence [from losing sexual desire]. You may be sad; it's like losing a job, but is losing a job a medical problem?" Tiefer said. "These are lifestyle issue concerns that are being medicalized by groups with financial interests, and that's something that all of us out to be very concerned about."
Tiefer is a self-identified feminist, but objects to the medicalization of what she says is normal female desire, or the normal lack thereof.
"This is the great advantage of having lived a number of decades longer and having been raised in a different time with different norms," Tiefer said. "Having sex was not considered a mental health need. Having sex was not considered proof of being a real person, a real woman. Sex was not considered the center of a relationship or the foundation of a relationship."
"Women have a right to everything that they can aspire to, including sexual pleasure if that's what they want," Tiefer said. Women, she said, can aspire to "ice-skating opportunities, jobs, and a house with a solid roof, but none of those are medical problems. Not being able to ice-skate or not wanting to ice-skate, these are not medical problems. But just because it's something that women have a right to doesn't mean we have to immediately medicalize the whole situation."
Some groups, including the American Medical Students Organization and the feminist nonprofit Our Bodies Ourselves, have raised concerns about the fact that flibanserin is taken daily and impacts neurotransmitters, unlike male sexual dysfunction drugs that are taken on an as-needed basis. That, they said in a letter to the FDA, "raises toxicological concerns that make it appropriate for the FDA to subject flibanserin to elevated safety scrutiny." (Tiefer is affiliated with one of the organizations, the New View Campaign, that sent the letter).
A better option, opponents like Tiefer say, is therapy, not pharmaceuticals.
But according to many women, the problem is biology, and no amount of work on the relationship will fix it.
"There's not enough sex therapy in the world that can cure this," Parrish said. "There are a lot of times in a woman's life when libido waxes and wanes. When I had four children under the age of 7, I didn't want to have sex. But it wasn't a lack of libido. It was physical exhaustion. My babies were nursing. There are a lot of valid reasons a woman's libido would disappear. But the key difference here is even in the absence of those things, still not having any desire."
Going off flibanserin, Parrish says, was "traumatic." She got the call telling her the trial was over after less than a year and she had to return the remainder of her dose as she was driving to her doctor's office to get more of the drug. "I was trying to think of a way to confiscate the pills, tell them the dog ate 'em," she said.
Over the next few months, she tried to compensate. She read Fifty Shades of Grey "at least 12 times." She tried prescription testosterone but found it didn't increase her desire and had less than ideal side effects, including acne and unwanted hair growth. She made it her personal mission to keep her and Ben's sex life active.
"I would find myself going into his closet and pulling out one of his ties, or going to Wal-Mart and buying a gray tie, just to be flirty enough so that he wouldn't think I was no longer interested," Parrish said. "I even ordered some stuff of the Internet, from god knows where, China, that promised me libido. And of course it came and I would take one and then freaked out because I don't know what's in here."
Parrish and Ben have been married for 10 years now, and it's been five since she went off the pills. She's holding out hope that flibanserin will be on the market someday soon, so much so that she and Ben went to Washington this past October to attend the FDA meeting on female sexual dysfunction and advocate for FDA approval of flibanserin. Parrish was floored when she encountered sex therapists who, she says, seemed to be at the meeting to oppose the drug in order to boost their own practices and who didn't seem to understand her situation.
"I had two or three people come up and offer me free Skype therapy, [telling me], 'What you just need is a good therapist; you shouldn't be wanting to have sex every day,'" Parrish said. "I've never had sex every day, even when I was 20. I don't want it every day when I'm 50. I just want to want to have sex."
Advocates say they are cautiously optimistic about this third round of FDA evaluations, but the stakes are high. Flibanserin has now been submitted three times; supporters of the drug doubt there will be a fourth. And if flibanserin fails, they say, other attempts at manufacturing a medical treatment for low female sexual desire may fall away.
"We feel like this is the last chance," "Even the Score" chair Scanlan said. "There are two, maybe three, drugs in the pipeline, and they're considerably behind when it comes to clinical trials. If flibanserin goes down, they're going to stop."
That's what worries women like Parrish.
"I'm gonna live a long time, I hope," she said. "I don't want to think that this is the end of my sex life."
This article originally appeared on Cosmopolitan.com. Minor edits have been made by the Cosmo.ph editors.