Earlier this week, the Food and Drug Administration approved Addyi, aka flibanserin, a drug that will supposedly help women struggling with low libido. The pill has been called "female Viagra" in a million misleading headlines. I sent some questions about Addyi to Dr. Lori Brotto. She's an associate professor in the Department of Obstetrics and Gynaecology at the University of British Columbia. Her research focuses on women’s sexual health, she has done groundbreaking work on women's sexual desire and arousal complaints, and she's regarded as one of the top experts in the field.

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DAN SAVAGE: The headline writers are calling Addyi—which the FDA approved yesterday—the “female Viagra,” and the drug company behind it (Sprout Pharmaceuticals) must be pretty happy about that. Are you and other sex researchers happy about it?

LORI BROTTO: In less than 48 hours after approval, Sprout Pharmaceuticals was bought out by Valeant Pharmaceuticals, a massive pharma company based in Canada. This move is not surprising, and confirms the suspicion of many sex clinicians that the search for the so-called "female Viagra" is more about profit than pleasure.

Most sex therapists I know and have spoken to (and most physicians as well, for that matter) believe that Addyi is only going to help a very, very, very small subgroup of women with low desire. The women who participated in the clinical trials were in stable, monogamous relationships, premenopausal, they liked their partners, were not depressed or had other significant stressors, they knew how to get aroused, and they were already having sex three or four times per month before receiving the medication! These study participants do not reflect the women who typically seek out sex therapists. The latter tend to have quite a bit more relationship dissatisfaction, low mood and anxiety, and a lot of stress in their lives. For many women with low desire, it is not so much a loss of desire for sex, but rather a loss of desire for the sex they are having! A medication that tweaks the brain’s serotonin is not going to improve communication between partners. It does not restore a woman’s low self-esteem. And it most definitely does not make an aversive relationship blissful.

I am happy when women have options for how to address their sexual problems, and so I’m all for having a safe and effective pill to do that; however, I do not believe that flibanserin is the answer that we’ve been looking for.

DS: Viagra doesn’t “treat low libido.” It helps a horny guy—a guy wants to have sex, a guy whose libido is just fine—get hard. What does Addyi do exactly?

LB: Addyi is a failed antidepressant, and like other antidepressants, it works on the serotonin system in the brain. There it decreases serotonin (and is thought to reduce inhibition), and it increases dopamine activity (dopamine being the neurotransmitter of motivation). But these findings were based on rat studies, and in humans, scientists really have no idea how Addyi works to improve women’s sexual desire. But unlike Viagra, it acts on the brain, and must be taken daily, regardless of whether a woman plans to have sex or not. In the clinical trials, the benefits of Addyi did not take effect until women used it for approximately four to eight weeks.

DS: Some are objecting to Addyi because it has side effects. But Viagra has side effects, too, doesn’t it?

Addyi: A failed antidepressant.
Addyi: "A failed antidepressant." PIGGU/SHUTTERSTOCK
LB: Yes, but the side effects of Viagra are relatively minor by comparison. The main side effects of Viagra are flushing in the face, a runny nose, and having a bluish tinge to one’s vision, and these affect about 15 percent of men. The newer erectile dysfunction drugs like Cialis and Levitra have far fewer side effects. Addyi, on the other hand, produced side effects in about 20 percent of women in the clinical trials. The main side effects were dizziness, sleepiness, nausea, fatigue, and dry mouth. Also, it is completely contraindicated with alcohol, so it will come with a black box warning that users cannot be consuming alcohol while using Addyi, or they are at risk of severely low blood pressure and loss of consciousness. This contraindication is unfortunate given that alcohol is often a great aphrodisiac! The concern about the loss of consciousness is that it can happen at any time, not only when the woman is popping the pill (at night). The main concern has been what if it happens while she is driving?

DS: Is having a low libido a condition—is it a problem—that requires medication?

LB: The medical field is so divided on this question, and I've seen fierce debates between the two sides: one side saying that low sexual desire is "a severe unmet medical need" and the other side saying "big pharma is creating a so-called medical condition so that there is a market for their cure."

If you take a random poll of 10 women and ask them if they have ever had a period in their lives when they lost desire for sex, a majority will say yes. That does not make low libido a condition. However, about 10-15 percent of women will say that their loss of desire is chronic (six months or more), that it is not just due to a stressful period, and that it creates significant personal distress—in other words, they seek treatment because their low sexual desire bothers them, and they are not simply asking for help at the behest of an angry partner. Even in these cases of clinically significant low desire, most of the research points to non-biological causes (again, mood, stress, body-esteem issues, poor communication, lack of sexual skills, etc. etc. etc.), and it is very unlikely that a medication will do anything to correct these. In the clinical trials, only 8-13 percent of the study participants had a good response to Addyi—an important fact that the sponsor rarely mentions.

DS: Do women struggling with low libido need a pill? Or is there something else they need?

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LB: I think Addyi should only be reserved for women who look like the women who participated in the clinical trials: premenopausal, having a sudden loss of sexual desire, know how to get sexually aroused, are in happy relationships with GGG partners, do not consume alcohol or yeast infection medications, are still having sex, but they miss feeling “horny.” For the other 95 percent of women, sex education, skills training, communication practice, learning how to get aroused, getting over relationship hangups, dealing with mood and stress, debunking oppressive sex-related myths, are what really improves their desire.

DS: Have you seen women who were struggling with low libido recover without drugs? If so, what was it that helped restore or raise their libidos?

LB: This group reflects most of the women in my clinical practice, and I use education, mindfulness, and sex therapy. I also help them rethink “libido” and work from a model that normalizes loss of horniness, but puts the responsibility on her (or them) to figure out how to excite her again. In many cases, when the sex is worth having, the desire for that sex returns.