Women's experiences negotiating sexual scripts in the face of sexual difficulties.

Author:Darrouzet-Nardi, Jaclyn
 
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Introduction

The Centers for Disease Control and Prevention (CDC) states that the rate of antidepressant use among Americans has increased almost 400 percent over the last two decades (2011). According to the CDC's U.S. National Health and Nutrition Examination Surveys, antidepressants are the most common prescription drug taken by Americans aged 18-44 and are the third most common prescription drug taken by Americans of all ages (2011). The popularity of these drugs is arguably a reflection of the pervasiveness of depression in our culture. An estimated 17% of Americans will suffer from a depressive disorder at some point in their lives (Kessler et al., 1994; Cockerham, 2003). At face value, these statistics obscure the gendered dimension of depression. In the U.S., women are twice as likely as men to be diagnosed with depression (Stoppard, 2000; Cockerham, 2003; Emslie, Ridge, Ziebald, & Hunt, 2005), and findings from epidemiological studies, community mental health surveys, and ethnographic research consistently reveal that women are more likely than men to experience depression across the lifespan (Stoppard, 2000). The National Institute of Mental Health estimates that women are 70% more likely to experience depression during their lifetime in comparison to men (2011). It is therefore no surprise that women are also more likely than men to be prescribed antidepressant medications. Additionally, two-thirds of all prescriptions for antidepressant drugs in the U.S. went to women (Stoppard, 2000) and according to the CDC, women are 2.5 times more likely than men to take antidepressants (2011).

Antidepressants have a variety of potential side effects, including fatigue, insomnia, nausea, weight gain, constipation, blurred vision, dry mouth, and problems with sexual functioning (Mayo Clinic, 2013). These unpleasant side effects are believed to be a major factor in many patients' decisions to stop taking antidepressants (Bull et al., 2002). In fact, despite being commonly prescribed, patient compliance with antidepressant treatment regimens is remarkably low. The American Medical Association estimates that 50% of people who begin taking antidepressants stop taking them during the first six months of treatment (Bull et al., 2002).

Despite the high percentage of women prescribed antidepressants, very little is known about women's experiences with antidepressants and their side effects. The small body of sociological scholarship on women's experiences with depression has yet to specifically address women's experiences with prescribed medication. Of specific interest to us is how little is known about how women experience the sexual side effects of these medications. Indeed, with regard to both depression and sexual functioning, women have been understudied relative to men (Stoppard & McMullen, 2003; Tiefer, 2004). Research indicates that the prevalence of sexual side effects among people who take antidepressants may be seriously underestimated by both pharmaceutical companies and physicians (Clayton et al., 2002; Hensley & Nurnberg, 2002). Thus the original intent of this research was to investigate the disjuncture between physicians' estimates of antidepressant drug- induced sexual dysfunction and women's self-reports of the same. However, over the course of this study, what became most interesting from a sociological standpoint was how the sexual side effects experienced by women who took antidepressants were experienced and negotiated in the daily lives of female patients. What was especially illuminating was how the respondents discussed their experiences with sexual side effects and how those experiences impacted their perceptions of their romantic relationships and their sexuality.

This study is based on qualitative interviews with 28 young women who identified themselves as having experienced sexual side effects while taking medication for depression or anxiety. Some of the respondents took a single medication to treat either depression or anxiety; some took a single medication to treat both disorders. Others took multiple medications, or switched from one medication to another, seeking relief from their symptoms. We do not attempt to make any claims about the effects of specific antidepressant or anti-anxiety medications on sexual functioning. Instead, we were interested in how women who self-identified as having experienced sexual side effects while taking their medication negotiated these experiences, regardless of their own personal diagnoses or the exact type of medication used.

Background

Sexual Dysfunction

The definition of "sexual dysfunction" has evolved over the years and from edition to edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is published by the American Psychiatric Association. The most recent edition, the DSM-5, was released in 2013. It classifies female sexual dysfunction into three categories: (i) sexual interest/sexual arousal disorder; (ii) orgasmic disorder; and (iii) genitopelvic pain/penetration disorder (IsHak & Tobia, 2013). For women, sexual interest/sexual arousal disorders include low libido and/or lack of vaginal lubrication; orgasmic disorders include persistent delay or absence of orgasm following the sexual excitement phase; and genitopelvic pain and penetration sexual disorder include painful intercourse and involuntary spasm of the muscles of the vaginal wall (Schweitzer, Maguire, & Ng, 2009).

As a diagnostic category, "sexual dysfunction" has been the subject of scathing feminist critique, especially as it has been applied to women (for example Irvine, 1991; Kaschak & Tiefer, 2002; Hartley, 2003; Tiefer 2004, 2006). Feminist critics argue that, as a category of disease, "female sexual dysfunction" is an example of "disease mongering," an illness created by the pharmaceutical industry and other "agents of medicalization" (Tiefer, 2006). For example, critics point to the desire of pharmaceutical companies to create a new market for their products following the success of the erectile dysfunction medication Viagra, (Loe, 2004; Moynihan, 2003; Tiefer, 2001). These scholars criticize female sexual dysfunction as yet another example of the medicalization of women's bodies, an attempt to standardize women's sexual performance and profit from the insecurities women are likely to experience when they are unable to meet those standards (for example, see Tiefer, 2006).

One element missing from the recent feminist work on female sexual dysfunction is a sociological explanation of how this "dysfunction" actually affects the women to whom the label might be applied. Women commonly report sexual problems as a side effect of antidepressant medications, yet we can find very little research about how they experience and negotiate those difficulties in their daily lives. Past research indicates that the prevalence of sexual side effects among people who take antidepressants is seriously underestimated by both pharmaceutical companies and physicians (Clayton et al., 2002). Currently, more doctors are encouraged to proactively discuss the sexual side effects of antidepressants with their patients because many are embarrassed to raise the issue (Schweitzer, Maguire, & Ng, 2009), and female patients are especially unlikely to broach the subject with their doctors (Stulberg & Ewigman, 2008). As mentioned previously, patient compliance with antidepressant medication regimens is low, and sexual side effects cause many patients to cease taking their antidepressants prematurely (Mitchell & Selmes, 2007; Schweitzer, Maguire, & Ng, 2009).

A variety of newer antidepressant medications were introduced within the last few decades. Selective serotonin reuptake inhibitors (SSRI's, such as Celexa, Lexapro, Paxil, Prozac and Zoloft) are the most common class of antidepressants prescribed (Mayo Clinic, 2013). Serotonin and norepinephrine reuptake inhibitors (SNRI's, such as Effexor and Cymbalta) are also commonly prescribed (Mayo Clinic, 2013). Both SSRI's and SNRI's have the potential for sexual side effects, though SSRI's are more likely to cause sexual side effects than are other antidepressants (Mayo Clinic, 2013). The most common sexual side effects of SSRI's in women are decreased desire and delayed or absent orgasm (Frank, Mistretta, & Will, 2008).

Sexual Scripts

In 1973, Gagnon and Simon applied social scripting theory to human sexuality in their influential text Sexual Conduct to help explain what motivates individuals to engage in sexual behaviors. They identified three levels of sexual scripts: cultural (messages at the societal or cultural level), interpersonal (interactions between people) and intrapsychic (people's thoughts and desires). These scripts provide individuals with a way to determine the appropriate sequence of sexual events and interactions (Gagnon & Simon, 1973; Gagnon, 1990).

Sexual scripts are gendered, and men and women are expected to behave differently. Specifically, the traditional heterosexual sexual script rests on a double standard that encourages men to be the initiators of sexual encounters and women to be the "gatekeepers" who employ strategies to avoid sexual encounters (LaPlante, McCormick, & Brannigan, 1980; Wiederman, 2005). Additionally, traditional gendered scripts encourage women to have few sexual partners and experiences, whereas men are encouraged to have many partners and varied experiences (Rose & Frieze, 1993; Wiederman, 2005).

Thus, the traditional cultural script for feminine sexuality emphasizes the idea that sex is "for men;" that is, sex is something that women provide for men in committed relationships (Barbach, 1982; Strong, DeVault, Sayad, & Yarbar, 2006). Women are constructed as sexual nurturers who put the desires of their male partners ahead of their own needs. According to this script, when women have sex, emotional security trumps pleasure as the desired outcome. Participation in sexual...

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