On Mother’s Day, articles about women often centre on pregnancy, childbirth and caregiving.
Less often discussed is women’s sexual wellbeing.
Over a million Canadian women are estimated to have hypoactive sexual desire disorder (HSDD), a condition of low or non-existent sexual desire.
But the condition is under-diagnosed and under-treated, clinicians say.
“A lot of women will assume that low libido is an inevitable consequence of aging, perimenopause and motherhood,” said Dr. Jennifer Wider, a New York-based women’s doctor, author and radio host.
In Canada, the only drug specifically approved to treat HSDD is Addyi. The drug is the subject of a new documentary, The Pink Pill: Sex, Drugs and Who Has Control.
In the film, numerous women claim Addyi reinvigorated their relationships.
“Your whole relationship — at least mine, with my husband — was stressed or strained,” Barbara Gattuso, a woman who participated in clinical trials for Addyi, said in an interview on the film.
“On the medication, I chase him. It is unbelievable. I love my husband tremendously, but with this drug, I love him even more, and our sexual experiences were incredible.”
Desire disorder
Hypoactive sexual desire disorder (HSDD) is defined as “a persistent or recurrent absence of sexual fantasies and desire for sexual activity, causing marked personal distress or interpersonal [relationship] difficulties,” a 2021 medical paper says.
Addyi was first approved in Canada in 2018. The prescription medication is taken as a once-daily pill.
Addyi is sometimes compared to Viagra, the blockbuster Pfizer drug introduced in 1998 that treats erectile dysfunction by increasing blood flow to the penis.
But Viagra acts on blood vessels, while flibanserin — the active ingredient in Addyi — works in the brain.
“[Flibanserin] specifically works on the dopamine, norepinephrine and serotonin systems,” said Dr. Lori Brotto, a professor at the University of British Columbia and executive director of the Women’s Health Research Institute.
Addyi must be taken every day for weeks before its effects become noticeable.
“This is why it shouldn’t be referred to as a female Viagra,” Brotto said. “Viagra acts peripherally … [and] gets metabolized through the system within four hours.”
Wider says low sexual desire is harder to define than erectile dysfunction. “Erectile dysfunction is really a vascular and physiological issue, so it’s very easy to measure,” she said.
Desire, by contrast, is subjective and shaped by multiple factors, which may contribute to it being dismissed in clinical settings.
“A lot of people say, ‘Well, it’s in your head’,” said Wider.
That perception, experts say, reflects broader attitudes toward women’s sexual health.
“Women’s [pleasure] is an afterthought or a nuisance or inappropriate,” said Brotto, who also holds a Canada Research Chair in women’s sexual health.
According to a 2015 Canadian study, about one-third of Canadian women report lower-than-desired levels of sexual desire.
But no national or provincial health survey directly measures HSDD. International research suggests HSDD may affect about 10 to 15 per cent of all adult women.
“[A] lot of women do have distressing[ly] low desire. Many have never been formally assessed or diagnosed,” said Brotto.
Low uptake
Despite the believed prevalence of HSDD, Addyi is rarely prescribed in Canada.
“The awareness [of Addyi] by both patients and doctors is pretty low … compared to the male side of the spectrum with medications like Viagra,” said Wider.
As of 2024, there had been only 936 recorded pharmacy dispensation claims for Addyi across B.C., Manitoba and Saskatchewan, according to data from the National Prescription Drug Utilization Information System. These provinces are the only jurisdictions where complete pharmacy dispensation data reflect both public and private claims for Addyi.
Addyi is not covered by public drug programs in other provinces, so it does not appear in publicly funded claims data, a Canadian Institute for Health Information spokesperson said.
Coverage under private insurance varies and is typically limited. And Addyi can be prohibitively expensive if paid for out of pocket. In Ontario, for example, a 90-day supply costs $880.
The Pink Pill documentary traces the difficult journey to get Addyi approved in the U.S. — and argues the drug was subject to a much higher level of scrutiny than drugs that treat male sexual dysfunction.
For example, when Viagra was approved by the U.S. Food and Drug Administration in 1998, it received priority review and reached the market in about six months. Addyi, by contrast, was rejected by the FDA on multiple occasions and took nearly two decades to be approved.
Brotto notes that the medical community had doubts about the drug’s efficacy.
“The data were not that impressive,” she said.
“When you look at the actual randomized clinical trials, there was a significant increase in sexually satisfying events of one per month compared to the placebo group … in the absolute sense, it’s really not that big of a difference compared to placebo.”
In the film, however, Addyi proponents note that even one additional sexual event a month can represent a meaningful shift.
“The studies show that there’s an increase in, on average, one sexually satisfying encounter a month, and a lot of folks will hear that and say, ‘One encounter a month. That’s very little. What? How is that even worth it?’” Dr. Francisco Garcia, a urology consultant and sexual medicine specialist at Cypress Regional Hospital, said in the film.
“My response to that, typically, is, when we’re treating somebody who has HSDD, they’ll be lucky if they have sex once or twice a year. Typically once a month is a monstrous change for some of these couples.”
Treating low desire
Although Addyi is one of the only treatments for low female sexual desire in Canada, it is not a miracle cure, says Brotto.
“It doesn’t change how much you like your partner,” she said. “It doesn’t change your mood. It doesn’t change your confidence in your body. It doesn’t improve your ability to talk about sex or overcome trauma histories.”
Brotto says psychological factors should be addressed separately. “There’s also a ton of data supporting psychological treatments like mindfulness and [Cognitive Behavioural Therapy],” she said.
She is also optimistic about an alternative treatment: testosterone therapy.
“The physicians that I work with, none of them prescribe flibanserin, but they regularly prescribe off-label testosterone,” she said. “There’s really good data to support testosterone, especially for postmenopausal low desire.”
In Canada, testosterone is only prescribed for HSDD off-label. It is, however, approved for use in treating HSDD in Australia and the EU.
Wider says topical testosterone can be more effective than Addyi for treating HSDD, but it can have unwanted side effects such as acne, hair growth and voice changes.
“Women deserve to know all the range of different treatments, including about flibanserin, including about testosterone and including about the role of even sex education,” said Brotto.
Experts say women’s sexual health has historically been under-researched and underfunded.
“We’re playing catch-up in women’s health research,” said Brotto.
“Women were [historically] not routinely included in clinical trials … data in most medical studies were not disaggregated by sex, so we’ve got lots of approved medications where the original trials either only recruited men or they didn’t look at the data separately for men and women.”
In Canada, fewer than seven per cent of national health research dollars go to women’s health, and the grants that do exist are often smaller and shorter term. Brotto says this needs to change.
Wider, in New York, notes similar barriers exist in the U.S.
“There’s such sexism that exists in a lot of these large governmental structures,” said Wider. “Male sex has always been prioritized over women’s sex, and male pleasure has always been prioritized.”
Brotto points to Bill S-243 as a sign of positive momentum in Canada. The proposed legislation would establish a national framework for women’s health in Canada.
“If it gets [passed it] will recognize the importance of women’s health in law,” she said.
