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Barbara Gattuso was in her late 30s when she first noticed a change in her attitude towards sex with her husband, Gregg. “I never spoke to him about it, but sex was just – I could care less,” she says. Over the years, Gattuso, now 66, became adept at hiding from her husband in order to avoid rejecting him outright; she’d often go to bed early, and get up before he did. "After a while, it was like ‘what is happening here? I love my husband, we have an incredible marriage, beautiful children; what is going on?’"

The problem was desire. While most people who’ve been in a long-term relationship can attest to a dampening of the initial fireworks over time, Gattuso had no interest in sex whatsoever. And it wasn’t just her husband; she couldn’t raise a flame for anybody. Some sexual psychologists claim that such fluctuations in sexual desire are perfectly normal  – particularly as women get older. Others believe this kind of desire deficit is a medical condition; the result of an imbalance of chemicals in the brain.

Now there may be a drug to treat it. On 3 and 4 June, the US Food and Drugs Administration (FDA) will convene an advisory panel to recommend whether Flibanserin – touted as the “female Viagra” – should be approved for use in patients, or confined to the dustbin. The question is divisive, however – with strong arguments for and against.

Faulty circuitry

So what causes this absence of sexual desire, and how might Flibanserin help? Women clearly aren’t alone in hitting against sexual problems as they age; the popularity of Viagra is a testament to that. To quote the comedian, George Burns: “Sex at age 90 is like shooting pool with a rope.” However, the nature of the problem often differs between the sexes.

There are three causes of sexual dysfunction in women: desire, desire, and desire 

“There is a saying in medicine that there are three forms of sexual dysfunction in men: erections, erections, and erections,” says Stephen Stahl, a psychiatrist at the University of California in San Diego. “And there are three causes of sexual dysfunctions in women: desire, desire, and desire."

The exact cause of this decline – and even the origins of desire in the first place – is something of a mystery to scientists, although they know that the brain’s reward circuitry is involved. One theory is that so-called hypoactive sexual desire disorder (HSDD) – also known as female sexual interest/arousal disorder – results from an inability to switch off the frontal parts of the brain that handle everyday tasks, like remembering to post a birthday card or resolving a problem at work. As a result, this reward circuitry, which deals in motivation and pleasure, is inhibited.

(Credit: Getty Images)

Once Viagra had proven so successful at treating male sexual dysfunction (not to mention lucrative for the company that developed it), a race kicked off to find a similar drug for women – but one that treats the brain rather than the genitals.

Flibanserin is one of the forerunners. Initially developed as an antidepressant, it was found to have little effect on people’s mood. However, women enrolled on clinical trials of the drug started to report an unexpected side-effect: feeling more interested in sex.

Flibanserin seems to work by tweaking the balance of signalling molecules (neurotransmitters) in these circuits – namely dopamine, noradrenaline, and serotonin. “We think it either normalises or compensates for whatever isn’t normal to make these circuits tuned,” says Stahl. “It may very well be that it allows women to disengage these frontal circuits that are inhibiting sex drive and interest.”

Rekindled lust

Although the drug was dropped as an antidepressant, because of its limited effect, it was soon being repurposed as a desire booster for women with HSDD. But although initial follow-up trials found that women reported an increased number of “satisfying sexual events”, they failed to demonstrate a significant effect on sexual desire. As a result, the FDA rejected the drug in 2010.

The average American woman has sex three times a month; if the patient didn’t have sex three times, does that mean the drug failed?

Further studies have, however suggested it does boost sexual desire after all – although the effect is modest. “The problem is: how do you measure an improvement?” asks Susan Scanlan, chair of the Even The Score campaign, which champions a drug solution to HSDD. (It’s worth bearing in mind, however, that Scanlan is paid a small fee, by a pharmaceutical company, to chair her campaign.) She points out that the baseline in general is low. “The average American woman has sex three times a month; if [the patient] didn’t have sex three times, does that mean the drug failed?” In fact, women on Flibanserin reported 2.5 sexual events in a 28-day period, compared to 1.5 in women with HSDD who were not taking the drug.

Certainly, some of the patients in these trials believe they have seen big improvements. Gattuso enrolled on a trial of Flibanserin in 2011. Initially she was given the placebo, which she says did nothing – despite her best efforts to rekindle her sex life. But after the trial had finished, she was offered a chance to take the real thing. “Within a couple of weeks I was a totally different person,” she says. “I would wake up in the middle of the night, and caress my husband. The closeness, the desire, that bonding, was totally 100% there.”

(Credit: Getty Images)

One concern, however, has been side effects that come with those improvements – including drowsiness, dizziness and nausea. Scanlan, however, points out that they are generally less extreme than those that come with Viagra and other treatments for erectile dysfunction. “Let’s look at some of the side effects for the 26 drugs that have been approved for men with sexual dysfunction,” says Scanlan. “We have heart attack, blindness, sudden death, and my personal favourite: penile rupture.”

Others fear that approving Flibanserin would encourage women to seek a medical solution for a problem that might be better resolved with relationship counselling, or by addressing other issues in their lives such as overwork or depression. “When it comes to desire, relationships are important, context is important, situational factors such as mood and privacy are important,” says Cynthia Graham, senior lecturer in health psychology at the University of Southampton in the UK.

Some fear that rejecting Flibanserin will stymie attempts to find effective alternatives.

Even so, she agrees that a pharmaceutical solution could be helpful in certain situations.“I do think that some women have problems with desire, and down the line I think it could be really helpful to have a drug treatment for women. But it needs to be a drug that’s clearly clinically significant, and we need to know more about the side effects,” says Graham. Some fear, however, that rejecting Flibanserin will stymie attempts to find other, more effective alternatives.

Last hope

Certainly, no one is suggesting that it should be a quick fix before many other factors, including tiredness, other medication, stress, and relationship issues, have been ruled out first.  “If you have a lack of interest in sex, you need to ask: is it just your husband, and you’re fine with the next-door neighbour, or is it a general lack of interest? A pill isn’t going to help a bad marriage,” Stahl says.

Gattuso agrees that there may be a place for counselling when there are genuine relationship issues, but she is adamant that it would be of little help to her marriage. “When you have a medical condition like diabetes, you can talk until the cows come home and it is not going to change that disorder,” she says. “HSDD is an imbalance in the brain.”

Patients like her see Flibanserin as their last hope: “When I was told the drug was being pulled I wasn’t just upset for me, but for hundreds of thousands of women out that have nothing to help them with this condition,” she says. “They need this drug.”

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