Empowered, Handmaid, or Rejector? The Framing of Low Libido in Women according to Scholarly Investigations of Public Communication

ABSTRACT

The quest for a Viagra equivalent for women has both reignited concerns over female oppression and rekindled hope for gender equality. Communication about decreased desire in women has come under intense scrutiny, especially in terms of the ways in which it may legitimize one view or the other. We present a systematic review of academic research on public communication about low libido in women and drugs/devices designed to increase it. A total of 1,309 records were screened, with 20 studies identified for final analysis (6 monographs, 11 articles, and 3 book chapters). Existing research found that the empowered frame predominated, according to which women sought to increase their libido of their own accord to enhance their individual sexual pleasure. The handmaid frame was described as somewhat less common; here, women resorted to treatment to save their relationships as they feared that inability to fulfill their “wifely duty” could alienate their partners. Importantly, scholars often reported that the empowered and handmaid frames co-occurred. The rejector frame, which suggested fluctuations in libido were normal and should not be medically treated, was described in existing work as least common. These results seem to suggest that low libido in women was constructed as a problem in need of a solution more often than not. As this may prompt women to think of their bodies as malfunctioning machines, it is possible that the framing of low libido in public communication can exacerbate existing trends toward pathologizing the waning of desire.

Introduction

The modern-day obsession with eternal youth has intensified a longstanding tendency to view the human body as a machine and age-related changes as suggestive of malfunctions (Overton, 2014). Although not indicative of poor health, routine accompaniments of growing older – such as thinning hair, wrinkles, and a decline in sexual desire or ability – are increasingly deemed abnormal and in need of rectification. This process through which “normal bodies and normal physical functions [are perceived] as problems” is known as pathologization (Wood, 1999, p. 322). Medicine plays a key role in this process, as changes such as those mentioned above are placed under medical authority (medicalization; see Conrad, 1992).

Out of a plethora of age-related changes undergoing a process of pathologization, this study focuses on public communication (and the academic assessment of that communication) concerning the waning of sexual desire in (aging) women. More specifically, we are interested in academic research of public communication about the “disorder”¹ itself and current options for treatment, taking the form of devices and prescription (Rx) or over-the-counter (OTC) medications. Rather paradoxically, the availability of treatment has managed both to reignite concerns over female oppression and rekindle hope for gender equality.

We report a systematic review of studies analyzing public communication about low libido in women, focusing on the drugs and devices available for treating it. We aim attention at the frames existing work has identified in this public communication. We present synthesized findings, assess the strength of evidence, identify research gaps, and hope to substantiate discussions on this hot-button issue. Public communication about low libido is worthy of academic scrutiny as the way sexual health issues are publicly discussed affects the extent to which they are placed under medical authority and pathologized. But so is the way scholars write about that public communication – our focus here – because these writings are targeted directly at those doing the diagnosing and treating of sexual health issues.

The pathologization of waned desire

Classifying a change in the body or bodily function as a health problem often prompts the development of treatment options, sometimes referred to as lifestyle drugs/devices. These are employed to enhance quality of life, satisfy a non-health-related goal, or treat problems that lie at the margins of health and wellbeing (Gilbert et al., 2000). The terms sexuopharmaceuticals and sexual enhancement products are sometimes used for lifestyle drugs and devices pertaining to sexuality. Their availability is considered to raise expectations that individuals will use them (Marshall, 2002), prompting Baglia (2005) to reflect critically on “a ‘take a pill’ society” (p. 29).

Throughout the modern history of human civilization, women’s low libido has preoccupied healers and alchemists, who tried to come up with potions and extracts to “fix” the “frigid woman” (Taylor, 2015, p. 263). Later, sex therapists and counselors entered the fray, suggesting that attempting to treat the body in isolation from the mind/soul may be shortsighted (Baglia, 2005). Over time, pharmaceutical companies replaced potions and extracts with OTC and Rx medications, a quest prompted by the success of Viagra after its launch in 1998 (Flore, 2019) – itself made possible by the FDA’s relaxing of regulations of direct-to consumer advertising and favorable media coverage (Baglia, 2005). Key players included Pfizer, Boehringer Ingelheim, and Valeant. At the time of writing, numerous OTC drugs for treating low libido in women exist, including Avlimil and Alista. The Food and Drug Administration (FDA) has approved the Eros-CTD (UroMetrics) and two Rx drugs, namely, Addyi (Flibanserin) by Sprout Pharmaceuticals (2015) and Vyleesi (Bremelanotide) by Amag Pharmaceuticals (2019). Addyi is dubbed the “pink pill,” while both Addyi and Vyleesi are commonly known as the “female Viagra.”² However, meta-analyses of medical studies have cast serious doubt on the efficiency of drugs and devices currently available on the market (Jaspers et al., 2016; Weinberger et al., 2019).

The social construction of libido decline

The pathologization of low libido in women can be both contested through communication and legitimized by it. Stated more formally, libido decline is subject to social construction. This means that the ways in which it is addressed in public communication do not express the reality of the matter, but rather, actively construct it (Dan et al., 2019; Lupton, 2000). Sexuality may lend itself more to social construction than other aspects of life do. Indeed, social norms, shame, or shyness may prevent many from addressing libido decline in personal interactions. In the absence of such direct exchanges, it may not even occur to women experiencing low libido to think about it as a disorder in need of treatment. Yet, public communication about this, especially media coverage (Hartley, 2006), can compel them to grapple with this possibility. Treatises on low libido in women – as encountered in news, magazines, newspaper advice columns, TV shows, disease awareness campaigns, advertising, and so on – are likely to influence the way women (and their partners) think about low desire and whether they consider it a problem in the first place.

Dominant norms, existing power relations, and sexual scripts are created in public communication and maintained/legitimized through constant repetition and enactment. Foucault (1978), for instance, argued that the medicalization of sexuality was motivated more by the desire to enforce social norms than the intention to cure health problems. As a result, certain ways of life appear worthy of appreciation while others seem objectionable. Knowledge acquired in this way is molded in unwritten guidelines for social interactions, internalized, and then enacted (Weis, 1998). To illustrate, viewing treatment options for low libido in women as an unnecessary and dangerous craze means valuing a specific way of life. This way of life is widely different from that connected to understandings of lifestyle drugs and devices as a liberating force able to advance sexual equality. It is different again from the view that treatment options can assist women in meeting their partners’ sexual expectations.

Three frames for libido decline in women

A wide array of studies using interviews with women experiencing low libido speak to the existence of various attitudes toward it and the related treatment options. Some women appear to see a decline in libido as a problem (Bahri et al., 2017; Woolhouse et al., 2012), while others choose to embrace it as something normal (Winterich, 2003). The goal of this study is to assess whether scholarly investigations of public communication about libido decline in women found this communication to follow a similar pattern. To facilitate understanding of our own analysis, we begin here with a brief review of existing research with women concerning their own sense of low libido.

Research has demonstrated that women with low desire for sex describe themselves through one of the following three frames: the empowered, the handmaid, or the rejector.³ Here, we use the term “frames” in the sense of “organizing principles [that] structure the social world” (Reese, 2001, p. 11) by selecting and emphasizing certain aspects of these women’s lives while obscuring others (Entman, 1993).

According to the available evidence, women who embrace the empowered frame are concerned with their personal pleasure and see an increase in libido as a pre-requisite for retrieving a fulfilled sex life (Ganahl, 2006; Neuhaus, 2000). They strive toward higher libido for their own sake, unapologetically, and out of their own accord, thus appearing as sexual agents in their own right. They see treatment options as part of women’s emancipatory movement and able to help them achieve sexual equality and open up new avenues for sexual expression.

In contrast to the empowered frame, the handmaid frame follows traditional ideas about gender norms. Researchers explained that women think of themselves as gatekeepers to men’s pleasure and sexual objects at their service (Jackson & Scott, 2001; Kingsberg, 2002), engaging in sex from a sense of duty to meet partners’ needs⁴ (Fahs, 2011). They seem grateful for the pills and devices available, and they are willing to start treatment. Women assuming this frame often appear passive, though this is not always the case. Sometimes, they are expected to “actively sexually service men⁵ and, furthermore, either ‘learn’ or pretend to enjoy it” (Tyler, 2008, p. 365).

Finally, extant research demonstrated that women embracing the rejector frame repudiate the construction of waned desire as a disorder, and argue that FSIAD is a made-up disease (Loe, 2004b; Winterich, 2003). A decline in libido is presented as something normal under circumstances like waned affection/routine in long-term relationships, childbirth, growing older, or recovering from an illness (Loe, 2004b). One should let nature run its course and refrain from meddling with women’s bodies with alleged easy fixes, such as pills or devices. In the words of Tiefer (2004), “sexuality is an option in life” and women are entitled to opt out (p. 145).

Methodology

We conducted a systematic review of academic and gray literature⁶ to assess the current scholarly understanding of the way low libido in women is socially constructed in public communication (see Jesson et al., 2011). We located, appraised, and aggregated evidence to reveal similarities and differences in research findings, propose explanations as to why they occurred, and identify gaps in current knowledge.

Data sources and search strategies

A broad search strategy was used. First, searches were conducted in seven academic and gray literature databases and content aggregators, specifically, Communication and Mass Media Complete, MEDLINE, SocINDEX with Full Text, Business Source Complete, Web of Science, PubMed, and Open Grey. Whenever possible, we used a Boolean search mode to identify relevant studies; otherwise, we introduced the key terms one by one. The search phrase, which can be obtained on request, included keywords describing the site of social construction (e.g., news) together with terms indicating either the issue at hand (e.g., FSIAD) or the treatment options (e.g., Addyi). We screened published and unpublished research returned by the searches.

Second, we conducted citation searches. We began by searching the reference lists of all studies deemed relevant until this stage to identify other potentially relevant studies. Then, we screened the publication lists of the most-cited authors (Loe, Moynihan, Tiefer, and Segal).

A total of 1,107 records were located in academic literature searches, 171 were collected from gray literature searches, and 31 were retrieved from citation searches. Of the 1,309 records, 1,105 were excluded by title. For the remaining 204 records, we screened the abstracts, or when none were available, we searched the full texts for our keywords to see them in context. This prompted the exclusion of 151 records. The full texts of 53 records were examined, leading to the exclusion of an additional 33 records. This brought us to a final sample of 20 studies for the systematic review. Eleven were journal articles, six were monographs, and three were book chapters. The PRISMA flow chart is given in Figure 1.

Figure 1. PRISMA flow chart

Inclusion/exclusion criteria and screening

The following inclusion and exclusion criteria were applied. Works were included if they contained an empirical study of public communication about low libido in women, pharmaceutical products (including active agents) or therapy devices that dealt with it. We eliminated biomedical studies (e.g., clinical studies) and studies focused on men’s libido or sexual ability. We excluded texts that only mentioned public communications (e.g., a specific campaign) without analyzing their messages.

Two study screening methods were applied based on the type of publication under scrutiny. For studies including an abstract, we screened the hits returned by the search based on titles, then based on abstracts, and finally, based on the full text versions. For records without an abstract, we used the search function to determine if the context in which the key terms occurred suggested relevance.

Data collection

The authors read each study in the sample individually and collected the information of interest. Except for the country of study, which was entered in an open field, yes/no questions guided the data collection. Furthermore, in each study, we highlighted paragraphs that dealt with the characteristics of interest to help retrace individual coding decisions and illustrate numerical findings. In a second step, we compared each data point collected individually and resolved disagreements by consensus.

Country of study

For each study, we recorded the country/countries in which public communication about low libido in women was analyzed in an open field.

Object of study

The type of public communication analyzed in each study was recorded by distinguishing between the following categories, which were not mutually exclusive: The news category was chosen for any form of news and journalistic commentary, as disseminated by television, newspapers, magazines, and so on. It also included newspaper advice columns. The entertainment category included movies, talk shows, and TV shows. Finally, the strategic communication category included all forms of persuasive communication, most importantly, advertising (e.g., billboards, TV ads, and print ads) and public relations efforts, such as campaigns, events, and press releases. In line with other researchers’ interpretation, testimonials of women attending the 2014 FDA Patient-Focused Drug Development Public Meeting – which is said to have played a major role in the approval of Flibanserin – were also categorized as strategic communication on behalf of Sprout Pharmaceuticals. As noted by Joralemon (2017) and Segal (2018), Sprout recruited women from participants in their clinical trials who were pleased with Flibanserin. They were selected based on what they intended to say before the FDA; their travel expenses were covered by Sprout, which had also coached them in Washington D.C. prior to the FDA meeting. Furthermore, the women arrived at FDA headquarters on a bus with Cindy Whitehead (Sprout’s CEO) on board, most of them wearing scarves and buttons with campaign logos.

Study methodology

We assessed whether studies resorted to quantitative, qualitative, or critical methods. The quantitative category was reserved for studies that reported systematically how the sample was chosen and how data were collected and analyzed using statistical means. The qualitative category was developed for studies that reported systematic in-depth analyses of smaller samples and used mainly inductive codebooks. The third category, critical analysis, was used for in-depth analyses that questioned the status quo, power relationships, and dominant ideology.

Frames

The three possible interpretations for women experiencing low libido and/or associated treatment options were operationalized along the lines defined in the literature review of studies involving talking to women (deductively) and inductively refined based on studies in which women were talked about. The empowered frame was coded as present when studies reported that women sought to rekindle their sex life for their pleasure and of their own accord. Accordingly, treatment options – especially Rx drugs – were described as revolutionary and attempts to restrict women’s access to them as sexist. The handmaid frame was coded as present when studies reported that women were presented as submissive sexual objects seeking treatment to better attend to their partners’ needs and save their relationship. Finally, the rejector frame was coded as present when studies described women as unconcerned about waned desire, seen as something perfectly natural rather than a disorder in need of medical treatment.

For a frame to be coded as present, the study would have had to deliver examples of data suggesting that low libido and/or treatment options were presented in that way – such as specific examples (quotes from newspapers, campaigns, etc.) in qualitative or critical studies, or numerical information in quantitative studies. This information was collected from the results section of journal articles and books (if they followed the typical structure) or from throughout the publication when results were interwoven with other sections. In each study, we coded as many of these frames as the authors accounted for.

Results

Characteristics of studies

All studies in the sample focused on the US context, with three also addressing public communication about low libido in Australia and the United Kingdom (Table 1). Most works analyzed were published in the 2000s. A peak in research occurred after the FDA approval of Flibanserin in 2015, with 12 studies published between then and 2019, the year when data collection for this study ended. The other, earlier studies focused either on Viagra when administered to women or the effect men’s use of Viagra had on their female partners.

Table 1. Characteristics of studies in sample (k = 20)

Variable	k	%
Country
United States	20	100
United Kingdom	2	10
Australia	1	5
Study methodology
Quantitative content analysis	–	–
Qualitative content analysis	–	–
Critical analysis	20	100
Object of study
News	10	50
Entertainment	2	10
Strategic Communication	18	90

Percentages do not always add to 100 as the categories are not mutually exclusive.

For the object of study, almost every study in sample analyzed the social construction of low libido in strategic communication (n = 18). Yet, only half focused on the investigation of news (n = 10). Entertainment formats were only seldom analyzed (n = 2). In the strategic communication realm, some studies analyzed ads for devices and OTC medication and found the rejector and handmaid frames to be predominant. Yet, most studies directed their focus at two competing campaigns titled Even the Score (ETS) and The New View (TNV).

According to the studies in our sample, the ETS campaign argued that placing low libido in women under medical authority was a necessary first step in developing much-needed treatment for women truly concerned about the loss of sexual desire and what it might mean for their health and/or relationships (see Hartley, 2006). Cindy Whitehead and the Berman sisters were described as being at the forefront of the ETS campaign. The former is the CEO of Sprout Pharmaceuticals, while Jennifer and Laura Berman are professors of gynecology/psychiatry and urology, respectively, and owners of centers focused on treating low libido in women (Cacchioni, 2015a; Fishman, 2004; Flore, 2019).

The studies in our sample reported that ETS’s challenger, the TNV campaign, maintained that variation in sexual desire was normal and largely due to nonmedical causes, such as emotional estrangement from a partner (McHugh, 2006; Tiefer, 2004). It was explained that they rejected the industry’s interference in women’s sexuality and argued that this interference sought to maximize manufacturers’ profits⁷ and improve men’s rather than women’s sexual experiences (see Hartley, 2006; McHugh & Chrisler, 2015). Further, the studies analyzed here explained that the TNV campaign criticized the “sponsored creation of a disease” (Moynihan, 2003, p. 45) through “disease-mongering tactics” (Tiefer, 2006a, p. e178), and contested the validity of a study widely referenced in the ETS campaign.⁸ The studies in sample identified Leonore Tiefer, a psychiatry professor who also has a sex-therapy practice as the main spokesperson of the TNV campaign.

Scholars analyzing news often focused on the extent to which the frames advanced by the two main frame sponsors (see Dan et al., 2019), ETS and TNV, were reproduced in newspapers, newscasts, and magazines. Ten studies engaged in surveys of large-circulation newspapers like the Chicago Sun-Times, The New York Times, and advice columns like Dear Ann or Dear Abby. Consumer magazines, including Cosmopolitan (n = 4), Vogue (n = 3), and Esquire (n = 2), were also frequently analyzed. Some studies investigated the coverage of low libido in TV news and documentaries, where national channels like ABC were predominant (n = 6). One study analyzed coverage on local radio. Numbers to do add up to 20 as most studies analyzed more than one communication context and/or more than one medium.

The prevalence of the handmaid, empowered, and rejector frames

Given the lack of variance regarding the method employed – all studies used critical analysis – we were unable to synthesize and contrast findings by methodological stream (see Petticrew et al., 2013). Hence, this section summarizes the findings obtained by the studies in the sample frame by frame (overall) rather than within each methodological stream. The studies included extensive direct quotations and in-depth descriptions of images from various forms of public communication. Due to space limitations, we only reproduce a few quotations per frame and context, and we describe only key images.

Overall, content suggestive of the empowered frame was described most in the studies in our sample, followed by the handmaid frame, with the rejector frame mentioned the least, as shown in Table 2. Indeed, some variations by context were reported in the studies analyzed. While the empowered frame was predominant in research investigating strategic communication (n = 17), the handmaid frame was reported slightly more frequently than the empowered frame in research studying entertainment formats (n = 3 vs. n = 2). In studies scrutinizing news, the empowered frame was encountered as often as the handmaid frame was (n = 8; see Table 2).

Table 2. Prevalence of frames by object of study

	Frames
	Empowered		Handmaid		Rejector
Object of study	k	%	k	%	k	%
News	8	40	8	40	4	20
Strategic communication	17	85	9	45	10	50
Entertainment	2	10	3	15	–	–

The total number of frames does not match the total number of studies as most studies reported the presence of more than one frame in the material analyzed.

Empowered frame

The empowered frame in strategic communication

Six of the studies analyzed found that OTC ads and the ETS campaign elaborated on the notion that treating low libido would bring about a sexual revolution (Cacchioni, 2015a, 2015b; Fishman, 2004; Flore, 2019; Graham et al., 2017; Hartley, 2006). Here, scholars indicated that women appeared as sexual agents wishing to increase their libido for their own sake, willing to take drugs to “enhance their sexual well-being” (Moynihan & Cassels, 2006, p. 190), help them “[s]top faking, get real” (Moynihan & Mintzes, 2010, p. 207) and achieve a “fuller, more satisfying sex life” (Hartley, 2006, p. 372; see also Loe, 2004a, p. 185). Consequently, researchers concluded that the ETS campaign claimed that denying women access to prescription medication (i.e., the FDA not approving Flibanserin) would be sexist as it would hold back options to enhance their pleasure (Segal, 2018, p. 466). Studies in the sample placed OTC ads, campaign messages, and excerpts from women’s statements before the FDA under this umbrella (Cacchioni, 2015b; Chańska & Grunt-Mejer, 2016; Flore, 2019; Joralemon, 2017; Jutel & Mintzes, 2017; Segal, 2015; Taylor, 2015; Tiefer, 2015). To illustrate this, we reproduce here a quote referenced by several studies in sample taken from the ETS campaign: The ETS reportedly set out to “level the playing field” as the score was now 26:0 – that is, there were 26 Rx sexual enhancement drugs approved by the FDA for men and 0 approved for women⁹ (Woloshin & Schwartz, 2016).

According to the studies analyzed here, key phrases used in strategic communication included “my right to medication,” “my turn now,” the need for “freedom of choice” for sexual enhancement drugs, and the “ability” to weigh drug benefits and risks in consultation with one’s doctor before deciding whether to start treatment (Graham et al., 2017). In a parody of a Viagra commercial, the ETS reportedly used the following tagline, “What the fuck? Are we really so far behind we don’t think women have the right to sexual desire? Yet again, we come second” (Flore, 2019, p. 6). As recounted by Segal (2018), this argument was also articulated visually through an image of older women shown locking hands in a row (the figure “26:0” surrounding them) and the reproduction of an image of the 1917 suffragists at a vigil outside the White House, their banner reading, “How long must women wait for liberty?” (p. 466).

Women speaking before the FDA reportedly reiterated the sexism reproach, stating they wanted “the same choices as men,” and protesting that, unlike men, they could not just go to their doctor and receive a prescription “within a couple of minutes for a drug that is insurance covered and FDA approved” (Segal, 2018, p. 468). Studies analyzing ads for OTC drugs found similar claims that access to pills represents sexual equality, such as “They have Viagra. Now we have Avlimil” (Hartley, 2006, p. 372) or “After all, men have their little blue pill … ” (Loe, 2004a, p. 163).

The empowered frame in news

Four studies reported having encountered in news the idea that Rx and OTC medication can revolutionize women’s sex lives by introducing a new epoch of female pleasure through increasing satisfying sex (Fahs, 2011; Flore, 2019; Loe, 2004a; Moynihan & Mintzes, 2010). To illustrate this, Flore (2019) and Loe (2004a) analyzed stories written for women’s magazines in which the authors “[took] the new female Viagra for a spin” and wrote at length the drug made sex “more fun,” making them “want it more” (p. 3, 126).

To illustrate, Flore (2019) reports how Amy Gamerman, the author of one such Vogue piece, talks openly about her discontent with her “sexual desire [that] had become elusive – less a basic instinct than a distant place on a map that had been rolled up and locked away.” According to Flore’s (2019) scholarly account, Gamerman – after having taken Addyi for a couple of days – reports that “something odd is happening: I’m suddenly thinking more about sex. I am not obsessed, just newly alert to erotic possibility, scanning the world around me for any sign of it. (…) My desire is improving, as is the quality of the sex. I’m more enthusiastic, less distracted. The color commentary that usually runs through my mind during the act – This is nice, but am I enjoying it enough? Is that a paint chip on the ceiling? – has fallen silent. The sharp edges of daily life melt, just a bit. (…) [A] virtuous circle has begun to take hold: I want it more often because I’m enjoying it more, which makes me want it more. I’ve already called in my refill” (Gamerman, 2015 as cited in Flore, 2019).

Six studies suggested that journalists covered low libido and treatment options in line with the sexism reproach (Flore, 2019; Graham et al., 2017; Loe, 2004a, 2004b; Segal, 2018; Woloshin & Schwartz, 2016). Loe (2004a) recounted how women featured in news wondered whether Viagra “will work for women, too?” and demanded their own “magic pill,” stating that “if men have Viagra, women need something too” (p. 104). Segal (2018) cited a reporter saying, “Drugs like Viagra and Cialis are all over the place. But women suffer from sexual dysfunction too. So why no pill for them? Turns out there is one, but you can’t get it” (p. 466). Flore (2019) reported that articles elaborated on the need to “get it right for women” and reproduced power images of Cindy Whitehead.

The empowered frame in entertainment

Two studies in our sample found content aligning with the empowered frame in TV shows. On Sex and the City, Samantha – one of the lead characters – reportedly tried the regular Viagra in an attempt to enhance her sex life and seemed very pleased with the effect (Moynihan & Mintzes, 2010). Loe (2004a) described how, on Oprah, the host introduced a demonstration of the EROS-CTD device by the Berman sisters with the words, “Women are finally getting some solutions to their sexual problems.” According to Loe, the demonstration was received with “giggles of delight by audience members and Oprah herself” (p. 141).

Handmaid frame

The handmaid frame in strategic communication

Nine of the studies in the sample reported that both the ETS and drug/device advertising presented women as seeking treatment for their low libido for the sake of their male partners (Fishman, 2004; Jutel & Mintzes, 2017; Taylor, 2015). According to these studies, while not personally distressed by their low libido, women cited in the context of the ETS campaign said that they sought treatment “at the request” (Segal, 2018, p. 477) or “insistence” (Taylor, 2015, p. 268) of their male partners. The men cited here were “thrilled” about the prospect (Flore, 2019, p. 13) of their female partners having an enhanced libido, as this “[gave] a whole new meaning to [their] four-hour erection” (Segal, 2018, p. 465). In the ads analyzed in the studies in our sample, drugs/devices were said to provide “sexual healing” (Moynihan & Cassels, 2006, p. 190) to women, making them “as happy as” their husbands (Fishman & Mamo, 2001, p. 191). Thus – judging from the studies included in our analysis – in advertising and the ETS campaign, drugs/devices were presented as relationship savers for women who “want[ed] to want” sex; treatment enabled women to “give” sex to their husbands, and thus, be “good wives” (Segal, 2018, p. 467) by becoming more like their former selves – the women their husbands had married (Graham et al., 2017; Segal, 2015).

The handmaid frame in news

According to the studies in our sample, newspapers, magazines, television and radio newscasts, and newspaper advice columns abounded in stories about women afraid that their low libido might break up their marriage because they were no longer able to perform their “wifely duty” (Loe, 2004a, p. 108; Hartley, 2006; Segal, 2018). The studies analyzed here concluded that male partners appeared to be both the source of this anguish and the direct beneficiaries of treating women’s low libido. Moynihan and Mintzes (2010) illustrated this with an example taken from an article in a men’s magazine, which was titled, “Where can I get some [female Viagra] for my girlfriend?” (p. 201). Four studies observed that media outlets ran human-interest stories positioning drugs as relationship savers (Cacchioni, 2015a; Fahs, 2011; Flore, 2019; Segal, 2018). For instance, Segal (2018) reported that one woman’s participation in the clinical trial for Flibanserin was said to have “save[d a] local woman’s marriage” (p. 467). In that radio show, the woman reportedly stated her wish for sexual enhancement drugs as follows: “I want to want it all the time … . I want to always desire my husband and I don’t want it to be situational” (Segal, 2018, p. 467).

The handmaid frame in entertainment

Two studies in the sample reported that, in TV shows, women were said to be “suffering in silence” over anxiety that low libido might cost them their relationships (Loe, 2004a, p. 141). In addition, two studies indicated that women were described as willing to start treatment with “pills, anything that will make me right” (Loe, 2004a, p. 162) – once again positioning drugs as relationship savers (Hartley, 2006). Loe (2004a) recounted that one of these women, Gabriela, has lost her sexual appetite following a major surgery (hysterectomy) in which nerves had been cut, making her less sensitive. Her interest in elevating her sexual desire for the sake of her partner was reportedly described in detail, including the numerous side-effects ranging from insomnia to facial hair and liver damage (Loe, 2004a).

Rejector frame

The rejector frame in strategic communication

Studies finding evidence of messages pointing to the rejector frame mainly referenced the TNV campaign (Cacchioni, 2015a, 2015b; Fahs, 2011; Flore, 2019; Hartley, 2006; Joralemon, 2017; Jutel & Mintzes, 2017; Moynihan & Cassels, 2006; Taylor, 2015; Tiefer, 2015). These scholars’ analyses of key campaign messages revealed that women’s libido was described as subject to natural fluctuations, and drug companies’ meddling in this process was vehemently rejected. Joralemon (2017) explained that this was addressed, for instance, in a music video commissioned by the TNV campaign titled “Throw that pink pill away” . Researchers have identified the goal of the TNV campaign as if it sought to “challenge the distorted and oversimplified messages about sexuality that the pharmaceutical industry relies on to sell its new drugs” and “to expose biased research and promotional methods that serve corporate profit rather than people’s pleasure and satisfaction” (Cacchioni, 2015a, p. 448).

The rejector frame in news

Several studies found that newspaper articles and newspaper advice columns addressed the idea that women were entitled to quit sex unilaterally and end their sex lives if they wanted to (Moynihan & Mintzes, 2010). Scholars perceived this view to be rooted in a recognition of the complexities of women’s sexuality and its link to overall satisfaction with one’s relationship and life rather than pure mechanics (Loe, 2004a). The studies in sample found that only few sex researchers featured in news held this position; reportedly, these sex researchers argued there was no point in making older women hold onto sex, especially since they might “find their hobbies more interesting” (Fahs, 2011, p. 122). Furthermore, studies analyzing newspaper advice columns found that women felt that they had “earned a rest” and that they had no interest in rekindling their sex lives only because Viagra had put their husbands “back in the saddle” (Loe, 2004a, p. 110).

Discussion

This study provided an overview of extant research focused on public communication about low libido in women and associated treatment options. The analysis suggested that public communication seems to follow a similar pattern as described by women in their own words (Bahri et al., 2017; Winterich, 2003; Woolhouse et al., 2012). Yet, while all three frames – empowered, handmaid, rejector – were encountered by the researchers whose studies we analyzed of public communication, important variations existed. Specifically, the empowered frame was reported to be predominant. The handmaid frame was found to come in second, and the rejector frame was described least frequently.

These results seem to suggest that low libido in women was constructed as a problem in need of a solution more often than not, potentially prompting women to think of their bodies as malfunctioning machines (see Conrad, 1992; Overton, 2014). Given the growing availability of lifestyle drugs/devices, this kind of framing is likely to raise expectations that women will resort to them to fix their bodies (Marshall, 2002). From a normative perspective, this may be considered troublesome, especially given the low frequency to which scholars encountered the rejector frame as an alternative view.

It is important to keep in mind that the empowered and handmaid frames delineated different beneficiaries of elevating women’s libido. The empowered frame saw direct benefits for the women seeking treatment, claiming to use medicine for their pleasure. By contrast, the handmaid frame saw these women’s male partners as direct beneficiaries, and described the latter as coercing women into treatment. For this reason, it should be beyond dispute that the handmaid frame adheres to traditional gender norms. Evaluating which of the other two frames (empowered vs. rejector) advances a “truly” feminist perspective is beyond our purpose here. But we note that the studies in our sample suggested that many feminists found the empowered frame to be shortsighted and naïve, and described the rejector frame as a sensible alternative (see Cacchioni, 2015a; Cacchioni, 2015b; Flore, 2019; Graham et al., 2017; Joralemon, 2017; Segal, 2018; Tiefer, 2004).

Also worth discussing are the reported differences apparent in the communicative contexts. While all frames were encountered in strategic communication, the ETS and drug/device manufacturers reportedly chose a dual focus (empowered and handmaid frames), while researchers found that the TNV used a single-message strategy (rejector frame). While this may be interpreted as signifying that the TNV was more skilled in staying on message, it is possible that audiences could find a dual strategy appropriate given the complexities of the matter. Future experiments could test this hypothesis. The finding that the handmaid frame was reported in the studies analyzed here to be just as prominent as the empowered frame in news may be due to the norm of balance which requires journalists to cover controversial issues by featuring conflicting views in an equal manner. However, if journalists were indeed pursuing this goal, one has to wonder why the rejector frame was not covered with similar frequency. Future studies could use interviews with journalists to determine whether the rejector frame appeals less to journalists. This is conceivable. An alternative explanation could be that the sponsors of the rejector frame were less skilled in articulating their frames, as Flore (2019) suggested.

Taken together, our findings suggest three more ways in which future research could enhance our understanding of the social construction of low libido. First, this could be accomplished by broadening the scope beyond the verbal component of national campaigns, large-circulation newspapers and TV shows. Content analyses of regional and local news and campaigns should be insightful, as would investigations of entertainment programming and analyses of ads for Rx medication. Given the strong visuals revealed by this systematic review of existing work, we also expect that exacerbating the focus on visuals will prove enlightening. Furthermore, focusing on communication in countries other than the United States should be informative. Regardless of communication context, modality, and country of analysis, those considering setting up a content analysis may find it rewarding to employ methods other than critical analysis. Indeed, as critical studies have already provided astute, in-depth observations, finding out precisely how widely used each of the frames is may be a good next step.

Second, there is much to be learned from experimental research. As of now, many concerns have been raised over how communication may (unnecessarily) engage in self-surveillance and exert pressure on individuals to take lifestyle drugs. Yet, the extent to which this occurs is currently unknown, as are the specific effects of the three frames on dependent variables, such as gender roles, information seeking, or intention to start treatment.

Third, future analyses of public communication should look beyond what is stated through text and images, and reflect on what was left out. We gathered the impression that heteronormativity may have dominated. However, based on our systematic review, it is impossible to tell whether same-sex couples (here, lesbian couples) were left out in public communication about low libido or whether the studies in sample did not report the way the topic was addressed in public communication. Given the limited visibility of non-heteronormative ways of life and its repercussions, expanding the focus in future analyses of communication seems advisable.

Limitations

Our findings may be held with a moderate level of confidence, but they do come with some caveats. As is common for systematic reviews, our findings are descriptive. In addition, despite our extensive search, because most work available to date did not pay attention to communication processes, our findings are based on a rather small sample of 20 studies.

Conclusion

As more drugs for the treatment of low libido in women are approved, this area of research is expected to grow quickly. Thus, we anticipate that many more studies on the social construction of waned desire will be conducted. Our systematic review must be regarded as a snapshot inventory. Still, having summarized key findings and identified gaps in research, this study enabled us to suggest directions for future research.

Notes

1. The American Psychiatric Association (2013) refers to women’s lack of desire to have sex, feel aroused, climax, or engage in intercourse without pain using the umbrella term female sexual interest/arousal disorder (FSIAD). This term replaces the female sexual dysfunction (FSD) that was commonly used previously (Hartley, 2006).

2. This term implies that Viagra and Addyi are comparable, which is inaccurate. Viagra deals with blood flow and tackles ability, while Addyi – as a repurposed antidepressant – targets brain chemistry and deals with desire for sex. In addition, Viagra is taken as needed, whereas Addyi must be taken daily (Segal, 2018). Worthwhile considering are also political and social considerations related to sexuopharmaceuticals. In many places, drugs treating erectile dysfunction are covered by insurance. By contrast, the so-called “female Viagra” is not, and consumers generally pay out-of-pocket (Perelman, 2016; Tiefer, 2006a; Tiefer, 2006b).

3. Upon the market release of Viagra, similar frames were described in the literature for men (Loe, 2004a; Vares & Braun, 2006). Like other bodies of research, this one is not characterized by a consistent use of names for frames (see Dan & Raupp, 2018). Thus, the frame names “empowered,” “handmaid,” and “rejector” are ours. They were chosen in an attempt to summarize the key tenet of each frame in one word.

4. As pointed out by Baglia (2005), such a binary thinking – according to which men seek intercourse for fun, and women give intercourse out of love – is both shortsighted and inaccurate. From the perspective of the present study, the “major revelation” is that science adds to these old-fashioned notions as “its own solutions propel stereotypes” (p. 36). Indeed, treatment options for men target physiology, whereas those for women target brain chemistry (Segal, 2018).

5. Obviously, this perspective is heteronormative, as lesbian couples may also experience withered desire and different levels of libido. However, to the best of our knowledge, behavioral patterns such as those associated with the handmaid frame were not described for lesbian couples.

6. This term denotes materials typically authored and published outside the academe, such as working papers, reports, and white papers.

7. The sales of Addyi alone were estimated at $10 million annually, with a potential market for this product trading much higher, at $2 billion (Reuters, 2017).

8. This study, authored by Laumann et al. (1999), suggested that FSIAD affected 43% of US women. It would later be discredited due to methodological flaws and two of the authors’ ties to Pfizer (Flore, 2019; Segal, 2018; Taylor, 2015).

9. The figure would later be described as inaccurate (Flore, 2019; Segal, 2018).