The Pleasure Gap

1 THE PLEASURE GAP

IN THE LOBBY of Building 31 at the Food and Drug Administration’s White Oak Campus, a display case houses a small but terrifying exhibit of recalled or otherwise perilous medical inventions. As I passed by, the iconic shape of the Dalkon Shield snagged my attention. An oblong disk ringed with spikes, in appearance it has been compared to a stingray or a crab, but it has also been described as an instrument of torture, which, it turns out, is precisely what it was. Marketed in the early 1970s as a “superior” intrauterine device—the Cadillac of IUDs for a new birth-control-savvy generation, the shield resulted in the deaths of more than twenty women and rendered at least thirteen thousand women sterile or infertile. By the mid-1980s, some two hundred thousand women claimed to have been injured by its use.¹

This totem to regulatory caution lingered in mind as I made my way into the FDA’s Great Room for the day’s proceedings. Although in the past the agency had weighed in on women’s access to quality contraception, that particular week in the fall of 2014 it was considering another matter: women’s access to quality sex. Several hundred experts, activists, pharmaceutical reps, and lobbyists had gathered to make—and contest—the case that female sexual dysfunction represented an unmet medical need.

Shortly after I entered, a woman who called herself Vicky took the stage and delivered an emotional testimony. Thirty-nine, a mother of four, she said she used to enjoy her sex life with her husband. “Our friends would even make comments about how we couldn’t keep our hands off each other.” But out of the blue, her desire vanished. It became nonexistent. She turned to specialists, but in vain, and tests revealed no ready answers. Her symptoms worsened; she found herself avoiding even “simple hugs and kisses.” Matters came to a head during a child-free escape to Mexico. “In the past when we had taken vacations together we barely left the room,” she said. “My mom always joked, ‘don’t get pregnant’ when we left. But unfortunately my symptoms stayed the same. In a beautiful place with the man I love, my body was like a shell with nothing inside.”²

As the conference continued, a steady parade of women came on stage to explain how their libidos had been whittled down to a fraction of their former size.³ For some it was a gradual diminishment. For others it was “like a switch that went off.” One woman lamented, “I don’t even think about sex.” Others spoke of how intimacy had become more a form of duty than a source of delight. “I am able to grit through it,” said one. Another: “I might not even want to have sex but if he wants sex and I give it to him then, yes, I was a good wife today.” One woman, who had spent over $35,000 on thirty specialists for treatments that included pudendal nerve injections, painkillers, and muscle relaxants, said her diminished interest affected far more than her sex life. In addition to the pain, it caused depression and low self-confidence and undermined her relationships with friends and family. One after another, the women described the anguish provoked by their dimmed desire: anxiety at the mere thought of sex, heartache over their inability to enjoy what they once heartily did, shame and embarrassment about something so essential having gone awry, disconnection from their bodies, and injury to their relationships.

The loss of female libido is a relatively recent addition to the annals of human suffering, one made possible by modern revelations about human health and sexuality. Authorities in the nineteenth century belabored women’s frigid temperament, at times insisting that their coldness reflected a natural antipathy toward sex; however, by the mid-twentieth century, frigidity had been recast as a form of pathology. Healthy women were expected to be receptive to intercourse, so long as it took place within the proper social bounds of heterosexual marriage, and within these strictures they were supposed to enjoy their sexuality. But somewhere along the way, in the midst of the sexual revolution, women’s liberation, and the Stonewall riots, something changed. Otherwise healthy women began to report that they were losing their appetite for sex—or at least for the kind of sex that was expected of them. Suddenly, it seemed that desire, once believed to be the steady propeller of erotic life, was becoming vulnerable. In 1980, a new diagnosis appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM) the so-called bible of psychiatry: inhibited sexual desire. Within a matter of years, it was the most prevalent sexual complaint of women in America.

Whether in the hands of poets or physicians, sexual desire has been defined in various ways, from the wondrously ethereal to the ploddingly mechanical. For the purposes of this book I have thought of it in terms of hybrid longings: to be sexual with oneself or another person; to experience pleasure; to experience connection; to become the object of another’s hunger; to express one’s own passions; to gain access to one’s interior self. Today, experts estimate that roughly one-quarter to one-half of American women experience low desire and other sexual concerns, including diminished arousal, difficulty reaching orgasm, and the presence of sexual pain.⁴

However, pinpointing the number of women who struggle with these issues is tricky, because the statistics shift markedly depending on how you approach the subject. How, for instance, are we to understand what is high or low, normal or unhealthy, in realms as subjective, mysterious, and thoroughly unquantifiable as human sensuality and sexuality? What is the baseline for comparison, and to what extent should we regard the documented differences between male and female sexuality as artifacts of the given age, as opposed to a realistic capture of essential distinctions? What, moreover, are we to make of the fact that women so often have sex for reasons other than the simmer of lust? Some interpret such reasons as evidence of a lack of underlying motivation—that women have a lower drive—while to others, they chiefly reflect the social circumstances of intimacy. And when we find that experiences differ across peoples, times, and places, that passions wax and wane, and that bodies can rise in thrall or turn insensate, should we look to biology as the arbiter of Eros? Or are our most intimate sensations inextricably bound up in the web of people, pressures, and ideas that surround us? Barraged as we are by sex-saturated messages that either neutralize or ogle at our marvelous diversity, do we hold ourselves hostage to harmful fictions that cannot accommodate the fluctuations that occur naturally over time? Or perhaps the only valid measure is the most elemental yearning: our desire for desire, wherein pleasure is our birthright and satisfaction our due.

From the vantage point of just a half-century ago, the sexual world we occupy today would scarcely be imaginable. We have benefited from a sustained momentum toward liberalization and equality whose impact has rippled across our laws, our institutions, our relationships, and our imaginations. But as Michel Foucault argued in the late 1970s, it is impossible to simply liberate sexuality as though springing an animal from its cage. Sexuality is not a stable thing, but rather a tapestry that we continually unravel and reweave. To agitate for liberation—as we have, and as I believe we should—begs the question of what our social churnings have accomplished against the next horizon line visible from today’s standpoint.

In this book I take as my starting premise that the sexual revolution is unfinished. By that I do not mean to imply that nothing was gained through the sexual convulsions of the 1960s and the women’s and LGBTQ movements that followed. Far from it. Today, in many ways, we enjoy an unprecedented level of sexual freedom. We are now engaged in a remarkably vocal debate over the meaning of both sexual difference and gender equality. It practically smacks of the caveman to assert male domination over women or to claim that heterosexuality is the more correct identity. Though we’re struggling to make sense of what parity really means, and what it looks like in practice, as historian Jeffrey Weeks has put it, “the real achievement is that inequality has lost all its moral justification.”⁵ In place of the presumed, and at times socially enforced, ideal of monogamous heterosexuality within marriage, today’s world is home to multiple forms of sexual identity alongside countless opportunities for exploring eroticism in both public and private life. The idea that women should be exclusively available to their husbands has been steadily eroded and paved over by a new culture that, for better or worse, encourages women to flaunt their sensuality and revel in sex as a source of casual recreation. Rape is condemned as the crime that it is, rather than dismissed as a social lapse, and the country’s leading pundits are weighing in on the true meaning of consent while also reckoning with the implications of its all-too-frequent absence. We’re also in the midst of what British sociologist Anthony Giddens has called a “transformation of intimacy.”⁶ Our very rationales for romance, partnership, and sexual expression have changed dramatically. Instead of seeking partners for security and companionship, we have, in the words of one set of researchers, portaged our unions to the peaks of “Mount Maslow.”⁷ We expect our intimate partners to aid in our quest for self-realization.

To the passing glance, it would seem that we, as a culture, are more sexually liberal than ever. Compared to the early 1970s, today’s Americans are more accepting of premarital sex, adolescent sex, and same-sex activities.⁸ Rates of casual sex have increased, and married people are having more sex outside of marriage—or at least admitting to it more—as well as placing a greater premium on the quality of sex within marriage. Individuals report having sex earlier on in new relationships, as well as engaging in a wider range of sexual acts.⁹ Survey data suggest that a quarter of women gave oral sex in their last encounter (though only 10 percent were on the receiving end), and that one-third of sexually active millennial women have anal sex “at least some of the time.”¹⁰ (For comparison, data from the 1990s showed only about one-fifth of women reporting that they had ever had anal sex, with less than one-tenth having done so in the past year.) We’re also increasingly using sex as a way to communicate with one another. These days, we widely share our sexual stories—of our first times, of coming out, of surviving abuse, of learning how to orgasm—as a way to mark our place in the world and describe this time in history.¹¹ Technology is further broadcasting and transforming our sexual behaviors. In addition to sexting and lobbing explicit content between personal devices, individuals are creating mammoth amounts of noncommercial porn—apparently to the delight of consumers, who watch it with discernible commitment.¹² A slew of dating apps facilitate no-strings hookups, homing in on available bodies in the vicinity—there are so many out there that third-party sites now rank them for you.

And the media, of course, both responds to and reinforces these trends. Never before has the popular culture been so inundated with allusions to sex, representations of it, and promises to help achieve pleasure. Our daily lives are positively saturated with depictions of sex that are casual in their abundance and yet increasingly explicit in their content. It’s no longer a mere truism that sex sells, in media-speak. Instead, in our multiplatform screen-time-all-the-time existence, there is a swampy blur of advertorial, personal confessional, and elevated raunch, which all the while preserves the omnipresence of the female body as the fetishized stand-in for what she is meant to sell.¹³ Perfume ads allude to semen dappling bare skin. Designer campaigns pair denim with scenes of date rape. In advertising for their “BK Super Seven Incher,” Burger King couldn’t resist posing a pert-mouthed blond gaping at an oncoming meat-filled sandwich. Primetime TV shows, which skew increasingly explicit, muse on the benefits of masturbation, the ethics of blow jobs on first dates, and the erotic potential of the “micropenis.”¹⁴ In response, entrepreneurs have eagerly swarmed to meet our new demands. Gwyneth Paltrow’s Goop website advertises 24k gold–finished vibrators alongside alpaca sweaters and fine-line-eliminating balms. Subscription services aim to teach women how to orgasm via online instruction. And a bumper crop of millennial-oriented websites garner clicks by running features on my first time fisting and tell-all accounts of polyamory. Teen Vogue published a guide to anal sex.

However, for most indications of progressive momentum, we confront caveat upon caveat. I would argue that many achievements of the revolution remain only partially realized, while some have been so thoroughly repurposed by our neoliberal climate as to be barely recognizable. Though American women today now have roughly equal access to education and health care, our status lags behind men where it concerns wealth, material security, physical safety, and health outcomes, including—critically—our sexual health. And these differences reach their most extreme levels for low-income women and women of color, for whom promises of wellness and prosperity often fall flat. Despite overperforming in higher education—women are in the majority among undergraduate students, and since 2009 have outnumbered men in earning doctorates—we still take home the lesser share of the payroll.¹⁵ Although the division of household labor is more democratic than ever, women still assume the brunt of domestic and emotional labor—and are expected to do so. Sexual violence, in spite of its increasing public visibility, remains stubbornly endemic. Meanwhile, women are disproportionately plagued by eating disorders, poor body image, low self-esteem, and mental health conditions. Indeed, women are diagnosed with post-traumatic stress disorder (PTSD) at more than twice the rate of men—and that includes men who have seen armed combat.¹⁶ Although women have new license to roam, they still contend with near-constant objectification—coming not only from the outside world, but also, and more disconcertingly, from themselves. Even as we celebrate women’s agency and autonomy, the “male in the head” can persist in undermining our embodied sense of power, begging the question of who benefits from our more visible sexuality and attendant expectations for nonstop lust.¹⁷ Some commentators have gone so far as to argue that the terms of sexual liberalization have subverted women’s interests.¹⁸ Whereas once the culture circumscribed female behavior by insisting on propriety, it now casts women as hypersexualized creatures of desire.

These tensions are playing out in America’s unique fashion, in which the public gorges on explicitness while finger-wagging a censorious morality. Even as we have grown accustomed to seeing nude or near-nude figures stalk across screens and billboards, Americans remain reluctant to engage in frank discussion about the basics of anatomy. We may be comfortable with raunch, but we are uneasy in the face of simple reproduction. Over the past two decades, the US government has spent more than $2 billion on sex-stigmatizing abstinence promotion programs.¹⁹ In 2011, it is estimated that nearly half the nation’s 6.1 million pregnancies were unintended.²⁰ As recently as 2012, Michigan state representative Lisa Brown was barred from the statehouse floor for using the word “vagina” in a speech.

However, it is in women’s bodies and in their relationship to pleasure that this unfinished business is most apparent. In simple terms: our libidinous cultural moment may not actually be all that pleasurable, because a giant share of women are not satisfied with their sexual lives. Between low desire, absent pleasure, genital pain, guilt, shame, quiet self-loathing, and viewing sex in terms of labor rather than lust, it would seem that we have increased sexual quantity without improving sexual quality. The revolutions of decades past have stopped short of the bedroom door, and women’s feelings in their own skin have not kept pace with our supposedly liberal climate. Our social and political empowerment has yet to encompass our complete humanity—that being full access to our erotic selfhood and its unencumbered expression.

This state of affairs becomes even more troubling when you look at how women compare to men on many of these issues. To be certain, men shoulder their share of sexual difficulties and dissatisfactions. While female libido tends to be underappreciated, as a culture we overemphasize male sexual appetite and denigrate men’s needs for intimacy and nurturance.²¹ Nonetheless, whether in terms of sexual dysfunction rates, sexual anxiety, or sexual pain, women appear to be having a harder time in their intimate lives. Compared to men, they report less satisfaction during their last sexual encounter and less satisfaction over their lifetimes. Regardless of sexual orientation, women are having fewer orgasms and placing less importance on the value of their orgasms compared to those of their partners. They also don’t appear to be taking delight in the recent additions to America’s standard repertoire: despite historic highs in the number of women having anal sex, for example, a significant proportion report not actually liking it. Strikingly, the same is also true of vaginal sex, which, in a recent survey of orgasmic frequency was a poor predictor of heterosexual women’s pleasure.²²

For the past several years, the subject of the orgasm gap has received much attention. The commentating world is troubled by the fact that men more reliably reach orgasm during sex. The gap here is freighted. It implies, as it is intended, to show an injustice that is social in origin rather than a naturally occurring difference. As a result, there are abundant calls for pleasure parity and orgasm equity. There is a nice ring to that, and in its dutiful way, the popular media has trotted out a number of ready fixes. For women it’s all about finding that missing climax—stress less, focus more, Kegel like crazy, exercise, meditate, embrace your inner goddess, excise your old repressive baggage, become a wild adventurer, be at once selfish and altruistic. For men, it’s about tricks to get her there: like a boss doling out a raise, it’s the guy’s job to furnish pleasure, frequently in parsimonious fashion—e.g., Bring your lady to boil quicker than a pan of pasta.²³

The way we’ve framed the problem—she gets less of that—is, I think, but a piece of the larger problem of treating female sexuality, including orgasm, as fundamentally elusive and difficult. It’s an approach that shrouds female sexuality in mystery and yet does not take into account the constellation of pressures and actual inequities that contour the way we experience our bodies and the world. Female pleasure likely will remain elusive and difficult so long as we—as a culture and as erotic individuals—approach sex as a linear experience that forecloses on the wider universe of eroticism.

CANARIES IN THE COAL MINE

Even as the evidence piles up that women are sexually dissatisfied, the experts are splintered over why. The subtext at the FDA meeting was the agency’s upcoming regulatory review of flibanserin, a failed antidepressant that an upstart drug developer, Sprout Pharmaceuticals, was trying to advance as a treatment for women with hypoactive sexual desire disorder, or chronic low sexual interest. Sprout and the researchers who trialed the product framed desire as a matter of neurochemical balance. If women’s libidos had tanked, the brain was to blame. Flibanserin is thought to work by decreasing serotonin and increasing dopamine, altering the neurotransmitters believed to inhibit and ignite desire, respectively. But this idea—like the drug—is highly controversial, as we’ll see later on.

A host of social scientists, by contrast, maintain that desire is a subjective experience, resistant to measurement and contingent on social, emotional, and contextual factors. To the degree that a woman feels her libido is lacking, it could be due to stress, anxiety, a history of trauma, poor body image, relationship problems, or just plain monogamy. Low libido might cause women distress, this group maintains, but it isn’t necessarily a disorder and may be a cultural creation, evidence of a media-fueled expectation that women constantly yearn to hop into bed, as well as the pharmaceutical industry’s rush to pathologize—and profit from—a condition that’s variable and natural. Leonore Tiefer, a psychologist affiliated with New York University and an outspoken critic of the medicalization of women’s sexuality, said at the FDA meeting: “There is no ‘normal’ that you lost.”

Much is at stake over how we choose to interpret the evidence. Whether we frame women as disordered patients warranting a pharmaceutical fix, as choice rich consumers shopping for their own brand of bliss, or as capable individuals endowed with the social and political capital to learn the rhythms of their own bodies, any approach we take will have far-reaching implications.

No small number of experts, either today or through the ages, have looked at female sexuality and concluded that women are not as libidinous, or desirous, or pleasure-seeking, as men—that they are innately