For Ellen, a 45-year-old college professor in rural Maryland, the music of the bedroom has never been as harmonious as it is in magazines. She cannot reach orgasm with her husband, and has only tepid interest in sex. "Frankly, it's the one fly in the ointment of our marriage," she says. Sexual couples counseling didn't help; her gynecologist, "eminently unhelpful," told her nothing could be done. Then she heard about a Baltimore urologist named Toby Chai who was conducting a small trial of Viagra among women with sexual complaints. She'd read of the miraculous results in men and thought this might finally dispel the "iceberg" intruding on her marital life. "It's not something we talk about every day, but it's always there." Returning home with six pills--three placebo, three Viagra--Ellen became a pilgrim in the increasingly frenzied search to unlock the mysteries of female desire.
Women's sexuality, Sigmund Freud opined, is the "dark continent" of the soul: an uncharted netherworld receding behind folds of flesh and muscle. Among the Big Ideas of the last century, few were as asinine as Freud's on sex and women, most notably his theory of penis envy. Yet in the decades that followed, science has continued to put forward as much ignorance as bliss. Until the late '20s, doctors manually stimulated women as a treatment for "pelvic disorder"; the vibrator, originally coal-fired, caught on as a way to shorten office visits.
In the 1950s and '60s, Alfred Kinsey and the team of Masters and Johnson began exploring female sexuality through the prism of its male counterpart. "We are still in a culture which has defined sexuality, sexual pleasure and [sexual goals] in male terms," says Dr. John Bancroft, current head of the Kinsey Institute. "Then we apply the same paradigm to women. That is a mistake." The male paradigm is simple: erection and release. Women's satisfactions and drives are more complex, organized as much around the health of the relationship as the majesty that is orgasm.
Add science to this simple insight and it becomes a program for revolution. Sparked by the stunning success of Viagra, and the prospect that it might be duplicated with women, a new era of sexual experimentation is now taking shape--this time not in the bedroom, but in the laboratory. "It's such a Wild West frontier of new discovery," says Dr. Irwin Goldstein, the media-friendly Boston urologist and pioneer in research on men and women. (Like many doctors interviewed for this article, Goldstein is a paid consultant and gets research money from one or more of the drug companies, but does not own stock in any.)
As many as four in 10 American women experience some form of sexual dissatisfaction, a figure likely to grow as the 41 million women of the baby boom, for whom unencumbered sex seemed a birthright, make the passage through menopause. The shadow cast by dysfunction can spread far beyond the bedroom, darkening a woman's entire sense of well-being. "It was probably in some ways more devastating than breast cancer," says a 55-year-old college professor who lost her ability to become aroused after hysterectomy. "This huge piece of who I am had just gone." Drug companies, research clinicians and traditional therapists are all leaping into the fray. Their work, still in its embryonic stages, is already starting to yield a radical new understanding of anatomy, dysfunction--and even the evolutionary meaning of orgasm.
A dozen drug manufacturers, including Pfizer, the maker of Viagra, are rushing headlong into research and development, mostly on drugs originally intended to treat impotence in men. Both male and female genitals have smooth muscle tissue that engorges with blood during arousal. Researchers hope Viagra will relax this tissue in the clitoris, as it does in the penis, allowing the vessels in the organ to swell with blood. The early prognosis, though, is less than thrilling. In the most comprehensive female trial of Viagra to date, released this week, the drug proved no more effective than a placebo. Nonetheless, Cheryl Bourque, an analyst at Decision Resources, projects that by 2008, the market for treatments for women, including testosterone and estrogen (sidebar), could hit $1.7 billion. Drugs conceived specifically for women, still perhaps decades away, could make this figure seem minuscule.
Jennifer Berman is one of the few female urologists working on the cutting edge of this research. At the Women's Sexual Health Clinic in Boston not long ago, Berman received a 54-year-old woman who, since menopause and a mastectomy, suffered vaginal dryness and pain during intercourse, and lost all interest in sex. "I feel like I'm less than a woman," the woman says. Berman wanted to test the flow of blood to the woman's genitals. Supplied with a pair of 3-D glasses and a vibrator, the woman watched an erotic videotape while an ultrasound probe resembling an electronic tampon monitored her blood flow--an attempt to tease out the physical component of dysfunction. Berman and her sister, Laura, a sex therapist, have become the telegenic faces of female sexual dysfunction, a two-headed Oprah for the erotically aggrieved. Together they tag-team the mind and body, a synergy many doctors believe will provide the best relief for female sexual dysfunction. For women, more so than for men, simply "medicalizing" the problem is too reductive. While many Viagra-enhanced men are happy just to get erections, fixing women's blood flow will cure little if libido-killing stresses still assail the relationship, the home life and the woman's self-esteem. Women presenting identical complaints might require a drug, a weekend retreat or a sex toy, or some combination of the three.
Even so, medical advances promise important keys. Anatomists are finding that we haven't even mapped the basic body parts. In a conference room at Boston University, Trudy Van Houten stops an unsuspecting medical student. The clitoris, she challenges the young woman, a fourth-year med student: how big is it? The woman looks momentarily stunned. Would you say it's one centimeter or 10? By the fourth year of medical school, students should know the gross details of the body, but this seemingly simple question has the woman in a pickle. "It can't be as big as 10," she tries. Oh, but it is, it is. "It's here, it's here, it's here, it's here," says Van Houten, tracing a finger across an anatomical drawing. "Wow," says the student. "Thank you."
The new research borders on the macabre: Goldstein talks of "harvesting" clitorises, labia and vaginas from cadavers, surgery patients or animals to study the microprocesses of sexual response; Cindy Meston, a psychologist at the University of Texas at Austin, has reported that stimulating the same branch of the nervous system that shuts down sexual arousal in men seems to facilitate it in women. Researchers like Van Houten are only now starting to map the myriad nerves that spider through the pelvic region, hoping ultimately to spare hysterectomy patients from nerve damage, as surgeons do when they remove men's prostate glands.
As they learn about the body, scientists are also rethinking the types and roots of dysfunction. They have identified four sexual woes: a low sex drive or aversion to sex, difficulty becoming aroused, inability to reach orgasm and pain during sex. Healthy women might experience any of these on occasion. They rise to the level of dysfunction only when they are persistent or recurring, and--most important--when they cause personal distress. Root causes can be physical (diabetes, obesity or other strain on the circulatory system), emotional (stress, fatigue or depression) or an interplay between the two. A cruel irony is that many drugs used to fight depression also dampen libido. For women now in middle age, the biggest threat to their sexual satisfaction may be social: after the age of 60 half of all women are without a partner.
Real help for many women is still far off. In his frenzied office at the New York Center for Human Sexuality, Dr. Ridwan Shabsigh proudly shows off a color photograph of dense, tangled tubes. His lab team, he explains, injected a hardening resin into the bloodstream of a live rat, then dissolved the rodent in acid, leaving only the solidified resin where the blood vessels used to be. The image, created with an electron microscope, describes the vascular system of a rat vagina. "This is big," he said--one giant leap for science, one bad date for Queen Rat.
Shabsigh's team of head and body doctors uses an updated theoretical framework for female sexual response. In the 1970s, the influential psychiatrist Helen Singer Kaplan sorted women's responses into three successive phases--desire to arousal to orgasm--a one-way arrow pointing straight to nirvana. The arrow model, says Shabsigh, ignores the more reciprocal play between the various states of pleasure. "We think of female sexual function not as a line but as a circle" joining the four points of desire, arousal, orgasm and satisfaction. Turbulence or interruption at any point affects the weather at all the others. In other words, today's frustration about orgasm dampens next week's libido.
Though libido is the most common complaint, most of the drugs currently being tested target arousal. Many doctors think this will limit the pills' future impact. But for women like Ellen, the Maryland professor, this is splitting sexual hairs. The quiet disconnect of her marital bed, she says, caused emotional stress for both her and her husband. She was hoping Viagra would jump-start her libido, but she wanted an orgasm, as well. "It'd be nice to have your cake and eat it, too," she says. Unfortunately, the pills did not work for her. "I haven't given up," she says.
Many of the drugs in development--VasoFem, Alista, FemProx--act a lot like Viagra, and this week's discouraging trial results are a potential wet blanket for the industry. "We're definitely continuing our research," says Heather Van Ness, a Pfizer rep. "We feel this [area] is significantly more complicated than erectile dysfunction." One researcher in the Viagra trials, Dr. Rosemary Basson, says the study may have incorporated too broad a range of ages and complaints to be definitive. Viagra may work for some conditions but not others. A more targeted study, limited to postmenopausal women, is now gearing up in the United States. Also being tested is a "dopamine agonist" called apomorphine, recently recommended for approval for use in men, which sends electrical impulses from the hypothalamus to the genitals to trigger increased blood flow.
Drugs, however, aren't the only potential stairway to heaven. Earlier this month the FDA approved an apparatus called EROS-CTD, a clitoral suction device the size of a computer mouse that draws blood to the organ. The device is available by prescription only and costs about $360. The best part of participating in the EROS trials, says a 35-year-old at-home mother in St. Paul, Minn., "is that we get one for free."
Hormone therapy is also promising, but can be a wild ride. Testosterone, for reasons no one quite understands, is involved in the sex drive of both men and women. In their 30s and 40s, most women experience a 15 percent drop in testosterone levels. Removal of the ovaries, often a part of hysterectomy, reduces production to near zero. At the University of California, San Francisco, Dr. Louann Brizendine has been experimenting with testosterone replacement therapy, in both oral form and patches. This is the tricky end of the erotic medicine cabinet: side effects include increased risk of heart disease and liver damage, and long-term consequences are unknown. Also, the surges of biochemical desire can leave patients reeling. One woman unwittingly doubled her dosage and had to excuse herself every few hours just to seek relief.
As biologists expand their grasp of amatory nitty and gritty, the thorniest riddle may be more global: why, from an evolutionary point of view, do women have orgasms? Unlike the male O, women's climax does not appear to be necessary for reproduction. The traditional answer, phrased by anthropologist Don Symons in 1979, is that female orgasm is a relic of Darwinian sloppiness, like male nipples: evolution had no good motive specifically to cut one gender out of the fun. If you think this argument has passed unchallenged, you haven't breathed the air on campus lately. Proclaiming orgasmic empowerment, anthropologists speculated that the sweet paroxysm kept women supine after sex, facilitating insemination--a dubious argument, since nature did not design most women to climax reliably through intercourse, especially in the missionary position. The evolutionary biologist Sarah Blaffer Hrdy proposed that this skittishness was itself an evolutionary adaptation: our unsatisfied ancestresses would seek remedy from multiple partners--in turn tapping each for protection and resources, and counting on confusion about paternity to multiply the generosity. Or maybe orgasm allows women to influence which mate will father their children. British biologists Robin Baker and Mark Bellis, who went so far as to attach micro video cameras to the ends of men's penises, found that women retained more of their partners' ejaculate if they reached orgasm as well. In an only-in-America study at the University of New Mexico, researchers Randy Thornhill and Steven Gangestad found that, other things being equal, women were more likely to climax when their partners' bodies were symmetrical, a marker of desirable genes. "It's all consistent with female choice," says Thornhill. Since competing explanations arise, you are free to accept this as gospel or just another reminder that the mysteries of sex won't be solved overnight.
The new science of sex, though, is not wholly academic. Revolutions in the lab will likely rearrange the bedroom, perhaps even the surrounding communities, in ways unforeseeable. As Jared Diamond describes in his book "Guns, Germs and Steel," new technologies often create societies' needs for them, rather than the other way around. Invention, in other words, can be the mother of necessity. Right now weare just approaching the cusp of that maternity. The dark continent is growing brighter and more electric with each turn of the circle.
It's both a mind and a body thing, and many women have a problem at some point in their lives. Doctors say sexual woes rise to the level of dysfunction only when they are persistant and - most important - cause personal distress.
Women produce testosterone in their adrenal glands and ovaries. Around the time of menopause, the amount produced declines, which may lead to a loss of desire, as well as fatigue and thinning hair.
Evolutionary biologists haven't yet figured that one out, and it's a controversial subject. One possible theory: orgasms in women have no function and are just a developmental vestige, like male nipples.