Barbara Gattuso had been happily married for decades when she signed up, in the late 2000s, for a clinical trial involving a potentially revolutionary new drug. She and her husband had once had a fulfilling sex life, both pre- and post-children. But at some point during her perimenopausal years, her desire disappeared. It wasn’t stress, fatigue or relationship issues, though her lack of libido certainly contributed to those. It was more like a mysterious evaporation – like “somebody pulled the plug”, as she recalls in a new documentary on flibanserin, the experimental drug that proffered potential relief.
Originally developed as an anti-depressant by the German company Boehringer Ingelheim, flibanserin had instead shown promise as a treatment for low female libido, working on neurotransmitters in the so-called “sex center” of the brain. In a video from that trial filmed by Dr Irwin Goldstein, the “godfather of sexual medicine” and a key consultant on Viagra – that revolutionary blue pill for men with erectile dysfunction – Gattuso appears nearly giddy. She was chasing her husband around again, she said. She felt “phenomenal”, like a “new woman on this drug”. She was plugged in.
That was back in 2010. It is shocking how quaint this footage looks and feels now, as it seems like this should have been an obvious breakthrough with cascading results. But as the Paramount+ documentary The Pink Pill: Sex, Drugs & Who Has Control demonstrates, the road to get flibanserin – often called, somewhat derisively, “the female Viagra” – to women struggling with their libido was anything but obvious, strewn with regulatory roadblocks, pharmaceutical price-gouging, sexist double standards and a profound societal disinterest in female choice, pleasure and experience.
Though the US Food and Drug Administration (FDA) approved flibanserin, sold under the name Addyi, for premenopausal women suffering from Hypoactive Sexual Desire Disorder (HSDD) back in August 2015 (and, as of last December, for women post menopause) most women are not aware that a drug for female sexual desire exists, let alone that it’s available. Until she was approached about making the film, “I had never heard of this drug,” Aisling Chin-Yee, the director, said. “I had never even thought about going in and talking to my doctor about my sex life. The only thing I’ve ever been asked by a doctor is, am I having sex or am I not having sex? And whatever answer I gave always seemed like the wrong answer.”
The Pink Pill examines just how persistent that disinterest in female sexuality, beyond reproduction, runs throughout the US medical establishment. As several sexual health doctors, gynecologists and urologists attest, most medical school curricula do not include sections on female sexual health, libido or clitoral anatomy. When Viagra was introduced in 1998, the medical establishment quickly adopted a drug that was seen as a breakthrough treatment for a physical issue in men. But the conversation around female libido and orgasm remained stagnant, often starting and ending with “it’s complicated”.
Frustration with this apathy and her own disappeared desire led Cindy Eckert, a pharmaceutical entrepreneur based in Raleigh, North Carolina, to buy flibanserin for $5m in 2011, after Boehringer Ingelheim decided not to fight for FDA approval. A hyper-feminine, distinctly 2010s entrepreneur with a fondness for everything magenta, Eckert renamed the drug Addyi after Dr Addison Grey, Kate Walsh’s character on the popular medical drama Grey’s Anatomy who represented the drug’s ethos of, as she says, “women living life on their own terms”. Her company, Sprout Pharmaceuticals, completed the necessary trials, demonstrating that Addyi improved the sexual drive and experiences of women struggling with HSDD. By October 2013, it was ready to go to market, subject to FDA approval. Though Addyi works on neurotransmitters in the brain, akin to an antidepressant, the FDA assigned its review to its urology division – a better fit for Viagra, which relaxes muscles and increases blood flow to the male genitalia. The FDA rejected it, claiming that the side effects – namely dizziness, nausea, fatigue and low blood pressure – did not outweigh the benefits.
The question of side effects – essentially, why would desire be worth it for women? – continued to dog the medication as it sought regulatory. The Pink Pill amasses a significant recent history archive of the “female Viagra’s” role in the culture wars of the 2010s, as Sprout mounted an aggressive lobbying campaign ahead of its 2015 hearing. Some of the backlash was predictably patronizing: “You might know [flibanserin] by its old name – wine,” joked Jimmy Fallon on The Tonight Show. Some was more grounded, such as pushback from those who believed HSDD to be a fictional condition to guilt women for their lack of sex drive, low libido medicalized in the name of pharmaceutical profit, with no medical consensus on what constitutes “normal” sexual desire.
The FDA questioned the potential for sedative effects, wondering if “a woman might take flibanserin the night before and get up the next morning and fall asleep taking her kids to school”, recalls Dr Anita Clayton, a University of Virginia psychiatrist and consultant to Addyi, in the film. “There was a very paternalistic attitude.” Data showing an increase of one “successful sexual event” per month was dismissed as ineffective – even though women with untreated HSDD experienced maybe one or two such events a year.
The bias showing through the FDA approval process boiled down to “well, we just don’t know if [Addyi] is necessary’”, said Chin-Yee. “But that’s not a question that has ever come up when it comes to male sexual dysfunction. It is absolutely imperative that if you are a man with a penis, you should be able to do whatever you want with it. And those were not the same considerations for women.” (The FDA, which denied any accusations of gender bias, did not respond to the film-makers’ interview requests. “I will give the benefit of the doubt to the FDA that they were in the midst of like getting Doge-ed,” Chin-Yee said, referring to the Elon Musk-led consolidation that gutted the department.)
Never mind that many women wanted their desire back, and felt less whole without it. “I thought ‘well, after you have kids, that goes away …’” says one HSDD patient in the film, frustrated by her lack of options and a prevailing narrative that “you’re a mother now and you focus on these things. That’s behind you.” The loss of sexual desire was “devastating”, says another whose menopause torched her formerly steady libido. “I felt like someone had slayed me.” Both Gattuso and her daughter testified at the FDA’s public hearing on the drug’s approval, speaking emotionally about the toll their diminished libido had taken on their lives. Opponents of the drug put the onus back on them; one recommended they instead try what worked for her: “switching boyfriends, chocolate, coffee, certain episodes of Grey’s Anatomy, pornography, upgrading my vibrator, read Fifty Shades of Grey, a removable shower-head and an acceptance of myself and the libido I came with”.
Photograph: Paramount
After much heated back and forth, the FDA approved Addyi in 2015. Eckert subsequently sold Sprout to pharma giant Valeant for $1bn. But the victory came with a major caveat: a black box warning, the most serious level available, for side effects such as dizziness, nausea and headache. Doctors had to take a test to prescribe it. Pharmacists had to take a test to fill it. Women prescribed Addyi had to sign a pledge that they would not drink alcohol. (Viagra, on the other hand, came with a recommendation that one merely should avoid alcohol.)
Faced with declining sales, Valeant more than doubled the price of Addyi, to $800 a prescription, making the drug cost-prohibitive. Then, in 2017, they shelved it altogether. What had once been the promising frontier in female sexual health was now essentially locked away. “How can you possibly pass something that is so wonderful for women and then have it ripped out?” says Gattuso in the film. “After all of this work, all of this emotion, we’re down to square one again. And we still are.”
Eckert managed to buy Addyi back from Valeant and start over. The drug is back on the market – though, if you google it, the first thing you will read is still a bold warning about side effects. Addyi proponents see a seriously stubborn double standard. There are 26 drugs approved for male sexual dysfunction, Chin-Yee noted, in part because no drug fits all. “That’s obvious, but for this drug and for women, it’s like, ‘well, if this could be a potential side effect, then the risk isn’t worth the benefit,’” she said. “And the benefit is only that women might enjoy their sex better. You know how many drugs come with nausea and dizziness and headaches? Those are things that pretty much every drug has on the side of their box.”
The through line, she emphasized, is choice. “You should be able to have that discussion with your own body and your own physician, rather than somebody just removing it as an option for you.” The film puts that pursuit of pleasure in context with a very different medical landscape than when Addyi first premiered, a post-Roe world in which women’s reproductive rights are under assault, healthcare for trans people is criminalized and bodily autonomy across the board remains tenuous.
Whether for abortion or orgasm, there’s nothing diminutive or inconsequential about choice, the film concludes. “You might think it’s funny and frivolous to say that women enjoying sex with their husbands is necessary,” said Chin-Yee. “But it is exactly that right being taken away that is related to all the other rights that could be taken away from you, and are being removed in the United States right now.”