A Pink Elephant in the Room?

You could see her waiting in the wings, peeking around the curtain, anxious for her debut on the public stage. And what a buildup; the opening acts pretty well guaranteed her a receptive audience -one that would assume that anything less than a full symphonic orchestral introduction and a dais at centre stage would be discrimination. Gender imparity. No, her time was already too long delayed; everybody had come to see Ms Pink Viagra perform –maybe even out-perform what had come before.

Well, okay, I understand the problem –I even suspect I understand the parity issues: it seems unfair to help the man with sexual dysfunction (read erectile dysfunction) while appearing to believe that any problem in the woman is just psychological… Or his fault. Beyond the Pale, in other words. The current situation is a vexing one to be sure and the answer is clearly not an easy one. But I’m hoping that we don’t merely end up prescribing medication alone for an issue that is almost certainly multifactorial.

There was a helpful, albeit preliminary, article on the subject in the Canadian Medical Association Journal this December: http://www.cmaj.ca/content/early/2015/12/14/cmaj.150705.full.pdf  At the time of publication, the American FDA had recently approved a drug (flibanserin) for the treatment of ‘acquired, generalized hypoactive sexual desire disorder’ in premenopausal women. The concern, in the Canadian context at least, was whether any company approved to market it would be able to adhere to Canadian law in advertising it: ‘direct-to-consumer advertising is not allowed in Canada, but direct-to-consumer information campaigns are legal’. One of the problems is the quality of evidence for the information supplied. For example, in the USA, the company selling it claims that ‘hypoactive sexual desire disorder affects as many as one in three women in the US’, whereas ‘reliable and independent scientific data show that only about 1 in 10 women experience distress as a result of their low desire and thus have the condition’. Suggesting, of course, that low desire does not always need to be treated; and therefore the corollary that low desire in either partner is not necessarily pathological…

I’m also concerned about the drug’s promulgation in the cause of equivalency. Fairness. If information about a product is what is allowed by law, surely neutral presentation of all that information is what was intended -expected, if not required. As the article suggests: ‘Bias is introduced if emotive campaigns that are not linked to strong evidence underpin the provision of information.’  And it goes on to say, ‘What about asking the more pertinent questions of whether the existing evidence can tell us if the condition really exists or whether drugs are the only response to a “dysfunctional” level of sexual desire?’ Indeed, perhaps the entire subject of sexual dysfunction in either sex requires a more critically based analysis.

I have to admit that, as a general gynaecologist, I have always felt very uneasy and ill-equipped for dealing with the subject of sexual dysfunction. It’s not that I find that it is embarrassing -I don’t (although the patients usually do); and I don’t mind that it is time consuming (my accountants not withstanding); it’s not even that it contains an undercurrent –often well disguised and overtly denied- of recrimination, blame, or guilt (although it can be all of those). No, I suspect that it is rather that the solution to the problem is seldom straightforward or easily solved. And, unlike an infection, it may require more than a pill to cure. It seems to me that the answer often lies with both parties –and each comes to the table with different perspectives. Different interpretations… Different appreciations of the issue, for that matter. Occasionally it may respond to empathetic listening, and the provision of impartial information along with counselling; more often it requires a multidisciplinary approach , or at least an expertise beyond that of the average practitioner, however well-intentioned. And that may be difficult to obtain in a timely fashion.

But as with depression, for example, it is often so much easier for the uncomfortable and busy practitioner to reach for a prescription pad after a brief hearing, and a subsequent cursory analysis of the complaint. And even if the medication, in the cool, reasoned glow of retrospect, turns out to be more of a placebo than a targeted and specific cure, well, that’s better than nothing… Isn’t it?

Maybe it is, but is it an example of critical thinking? Evidence-based medicine? Is it really the result of an honest and respectful consideration of the problem? If the condition is indeed often multifactorial, shouldn’t the treatment be that as well? I’m sure that the directions on the probably-pink package will make that perfectly clear, though… Right?







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