Are You in the 43 Percent?
I have long been fascinated by how it happens that some statistics make their way into the public conversation, taken for granted as being as reliable as pi—though if you gently blow on them, they disintegrate like dandelions. For example, Laura Kipnis, in her book Unwanted Advances, reports Edward Greer’s indefatigable investigation (in 2000) into the origins of the claim that “only 2 percent of rape allegations are false”—a claim taken as undisputed in most Title IX investigations. Greer found that all roads led to Susan Brownmiller’s 1975 book Against Our Will. She got it from a judge’s speech given to the New York Bar Association in 1974; the judge apparently was quoting a newspaper account, written, Greer learned, by a reporter who was a friend and neighbor of Brownmiller’s.1 (In a previous column, I discussed a further complication in the 2 percent claim, namely that an allegation doesn’t have to be false—that is, an intentional lie—to be wrong, a result of honest but incorrect perceptions and memories.)
Once a number enters the public arena and serves ideological, political, or financial interests, you can’t dislodge it with a barge pole. I found one such number in an article by Kim Tingley in the “Studies Show” feature of the New York Times magazine. I was pleased to see at last that “studies show” that when it comes to sexual interest and responsiveness to erotic stimuli (i.e., porn), female brains and male brains are pretty much alike.2 The reporter seemed amazed at this discovery, given that “other studies show” that men have a greater sexual appetite than women and are more “attracted to pornography.” The article reflects the widespread assumptions that (1) women’s and men’s brains are wildly different, (2) women’s and men’s sexual drives are wildly different, and (3) if we can just observe what the brain is doing when it is looking at porn, stiletto heels, or photos of erotic partners we will somehow be able to intervene and fix any sexual problems the possessors of those brains might have. “If men’s and women’s brains respond similarly to sexual stimuli,” Tingley asks, “what accounts for the apparent differences in how they approach sexual practices?”
Seriously, what accounts for “apparent” differences? One answer is beliefs and stereotypes, which have blinded many evolutionary scientists since Darwin’s day from noticing the vast examples from the animal and human world of, say, female promiscuity and male attachment, and which still blind many observers to the evidence of behavioral similarities between women and men. Of course men and women differ, on average, in some “sexual practices,” especially in cultures in which a woman can be shunned, excommunicated, banished, or murdered if she dares behave sexually “like a man”—and ditto for men who reject the hypersexualized demands of some cultures’ notions of proper masculinity. Both sexes might respond physiologically to pornography yet differ in the kind of porn they subjectively enjoy, never mind what their brains are doing. A sexologist colleague laments that modern porn goes directly to intercourse with no seduction to start—she misses the Handsome Plumber with Tool Belt story. There’s a sex difference for you.
Once a number enters the public arena and serves ideological, political, or financial interests, you can’t dislodge it with a barge pole.
Sexologists have been answering Tingley’s question—”what accounts for differences”—for decades: culture, situation, partner, age, religion, ethnicity, experience, status, power, personality, opportunity, the brain-numbing exposure to ads telling us what sex should be and could be, and, by the way, chances of getting pregnant. Ignoring this complex list, Tingley continues: “Answering that question means connecting the dots from what triggers the firing of specific neurons to how those firings give rise to the myriad thoughts and feelings we have about sex to the actions we take in response to them. Knowing what all this should look like neurologically could give clinicians more ways to treat the 43 percent of women and 31 percent of men who, according to the Cleveland Clinic, report problems in their experience of sex.”
“More ways to treat”? Clinicians will be able to treat sexual problems with what, brain surgery? Medication to correct the neurological wiring? Whatever the intervention, consider the huge number of people who supposedly need it: the 43 percent of “women” (all women? which women?) who have sexual problems. Where did that 43 percent come from? I thought you’d never ask.
When Viagra was approved in 1998, it was a bombshell, earning more than $1 billion for Pfizer in the year 2000 alone. The drug did so well, so fast, that Pfizer approached sexologists and urologists, trying to find a way to market it, or something comparable, to women. Before you can prescribe a drug for women, though, you must have a problem the drug will treat. Men have erectile dysfunction, but what do women have? There must be something comparable. It’s only fair. Accordingly, a new category of disorder was invented in 1999 by urologist Irwin Goldstein. He called it “Female Sexual Dysfunction (FSD)” and convened a conference to discuss it. Along with Jennifer Berman, a urologist, and her sister Laura Berman, a psychologist, the three published an article in the September 1999 issue of Urology, called “Female Sexual Dysfunction: Incidence, pathophysiology, evaluation and treatment options.”3 “Incidence” is very important, because you don’t want to spend millions of dollars developing a drug for a problem that only a few percent of the population has. The article began: “Female sexual dysfunction is age-related, progressive, and highly prevalent, affecting 30%-50% of women.” It’s progressive! This means the older a woman is, the more “dysfunctional” her sexual response is likely to be, although every survey from Kinsey to the present has found the opposite: as women get older, most become more comfortable with sex and more satisfied. The 30–50% estimates of the “highly prevalent” incidence of FSD came from small clinical samples.
You might think that something generically called “female sexual dysfunction” would include all the causes of a woman’s sexual difficulties: not only hormonal and physical but also psychological, cultural, and Harold. But because FSD was meant to be exactly comparable to male erectile dysfunction, the Berman et al. article chattered on about vaginal/clitoral blood flow, labial engorgement, and the neurogenic mechanisms modulating vaginal and clitoral smooth muscle tone; you will not find a single human being in this paper, certainly not one who is mad at her partner. The pseudosciency language sounded impressive but masked the emptiness of content:
Preliminary studies [not cited] suggest that vasoactive intestinal polypeptide (VIP) and nitric oxide (NO) are involved in modulating vaginal relaxation and secretory processes. NO has been identified in clitoral cavernosal smooth muscle. In addition, organ bath analysis of rabbit clitoral cavernosal smooth muscle strips demonstrated enhanced relaxation in response to sodium nitroprusside and L-arginine, which are both NO donors (unpublished observations).
(I was shocked to learn of my own abysmal sexual ignorance. I didn’t know rabbits had clitorises. This explains a lot, about rabbits anyway.) But I digress. The authors provided elaborate measurements of the arteries of 48 women who believed they suffered from “sexual dysfunction.” Not only was there was no control group, there was no problem, either: the authors acknowledged that in their 48 patients, “despite complaints of sexual dysfunction… sexual stimulation resulted in statistically significant increases in female genital blood flow.” In short, the parts were working fine.
The problem of prevalence got a major boost that same year, 1999, when the 43% number was published in JAMA—a report of The National Health and Social Life Survey, which had been conducted in 1992: “Sexual dysfunction is more prevalent for women (43%) than men (31%) and is associated with various demographic characteristics, including age and educational attainment.”4
The survey consisted of a probability sample of about 3,000 women and men aged 18 to 59. (After 59, apparently, no one has sex or can’t remember.) And here is how “sexual dysfunction” was determined: In interviews averaging 90 minutes in length, there was one yes-no question about 7 sexual problems: “In the last 12 months has there ever been a period of several months or more when you…”—yes or no?—lacked interest in sex, weren’t able to reach orgasm, came to a climax too quickly, experienced pain during intercourse, did not find sex pleasurable (even if it wasn’t painful), felt anxious about having to perform, and (for men) had trouble achieving erection or (for women) becoming lubricated?
How can a pill teach anyone how to kiss, how to talk, how to listen, how to negotiate differences, how to learn what they like or dislike …
There was no clinical evaluation, let alone a physiological evaluation, of any of these “yeses,” nor was anyone asked why he or she checked “yes”: was the partner in Tibet? Were there four children under the age of 5 in the house? Was the relationship rocky? Had one partner just had surgery? Was the woman having discomfort due to menopause? Were these chronic problems that had persisted for years or were they temporary? Was the respondent troubled by any of these problems? Nonetheless, 43% of the women said “yes” to one or another item in the list, and thus were recorded as having experienced “sexual dysfunction.” This term is as meaningless to a sexologist as “illness” would be to a physician: Are we talking about a cold or cancer? But for the pharmaceutical companies, that magic percentage of prevalence was all they needed, and off they went on a hunt for a blockbuster drug, comparable to Viagra, for all those suffering women.
They have yet to find it. In 2017, a cynical ad campaign for flibanserin, a drug that allegedly improves women’s sexual satisfaction, claimed that it isn’t “fair” that men have so many drugs for ED and women don’t have any. The drug, says its website, “increases the number of satisfying sexual events per month by about one half over placebo from a starting point of about two to three.” For an additional one-half of a satisfying sexual event a month, a woman must take this risky drug daily and avoid alcohol—most women’s aphrodisiac of choice.
Like Tingley’s enthusiasm for MRI studies of the brain twenty years later, the Berman et al. article was enthusiastic about the prospect of identifying the physical causes of female sexual dysfunction “thanks to recent advances in modern technology.” But their “modern” technology, just like the even-more-modern MRI study, found nothing that explains variations in sexual practices or satisfactions or problems. For that matter, now as then, no one has yet to agree on what “normal” sexual functioning is, let alone what “sexual dysfunction” is. Who decides what normal is? Who decides what a problem is? Most of all, how can a pill teach anyone how to kiss, how to talk, how to listen, how to negotiate differences, how to learn what they like or dislike, or how to cope with fear or disgust or anger as well as lust and excitement? If only it could! We could give every college student a four-year supply. Make that a lifetime supply.