Why Men Get Viagra and Women Get Therapy Referrals
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Show Notes
Same kind of complaint, very different appointment. He leaves with a prescription. She leaves with a suggestion to manage her stress.
In this episode Dr. Siân West, board-certified OB-GYN and menopause specialist, puts numbers on the gender pain gap many women have felt for years. She sets Viagra next to the first drug approved for low sexual desire in women and compares them on how well each works and on what each can do to you. The comparison doesn't come out the way most people expect.
Then she follows the pattern into the emergency department, heart attack care and the history of who got studied in drug trials, and finishes with the sentence to use when a physical symptom gets redirected to stress.
What you'll learn
The approval timeline, and the thirty-year head start sitting behind it
The side by side almost nobody runs: what each drug does, and what each one is allowed to do to you
What the 2024 pain study found at every single pain score, and whose pain gets written down at all
Why "women just report more pain" does not explain the gap
The exact sentence to use when a physical symptom gets blamed on stress: I would like this looked at as a physical symptom first
How to ask what specifically is being ruled out, and how
Why a second opinion is not dramatic
This is not an argument that individual clinicians are careless. Most people in medicine are trying, inside a system trained on incomplete information. The pattern is still real, and still measurable.
Questions this episode answers
Why did it take so long to approve a treatment for low sexual desire in women?
Sildenafil (Viagra) was approved by the FDA in March 1998 after roughly a six-month priority review. Flibanserin (Addyi), the first FDA-approved drug for low sexual desire in women, was not approved until August 2015, seventeen years later, and only after two prior rejections. Bremelanotide (Vyleesi) followed in 2019. Note that flibanserin was not the first approved treatment for any female sexual dysfunction diagnosis: ospemifene was approved in 2013 for dyspareunia due to menopause.
Are there really twenty-six approved treatments for men and none for women?
No. That figure came from the Even the Score advocacy campaign and was inflated. It counted testosterone products approved for hypogonadism rather than for sexual dysfunction, along with duplicate formulations of the same drug. A Hastings Center review of the campaign put the accurate count at roughly eight approved treatments for men and three for women. The disparity is real; the twenty-six to zero version of it is not.
How do Viagra and Addyi compare on safety?
Flibanserin (Addyi) carries a boxed warning for hypotension and syncope. Sildenafil (Viagra) has never carried a boxed warning. Its label includes a contraindication with nitrates that can be fatal, non-arteritic anterior ischemic optic neuropathy causing sudden vision loss, sudden hearing loss, and priapism that can cause permanent erectile dysfunction. Between March and mid-November 1998, 128 US deaths were reported in association with sildenafil; these were post-marketing adverse event reports rather than established causation, and many involved men with pre-existing cardiovascular disease. The FDA responded by strengthening the label warnings in November 1998, and the drug remained on the market.
How well does each drug actually work?
In sildenafil's pivotal trials, mean successful intercourse attempts rose from 1.5 per month on placebo to 5.9 on the drug, with 69% of attempts successful versus 22% on placebo. In a meta-analysis of eight trials and 5,914 women, flibanserin produced a mean of 0.49 additional satisfying sexual events per month over placebo. The difference in effect size reflects the difference in available science: erectile physiology had decades of foundational research behind it, and female sexual desire had very little.
Do women really get less pain treatment than men in the emergency department?
Yes. A 2024 study in PNAS of 21,851 emergency department discharge notes from the United States and Israel found women were less likely than men to receive any analgesic at every pain score and in every age group. Women also spent about thirty minutes longer in the department, and their pain score was ten percent less likely to be recorded by the triage nurse in the first place. The same bias appeared among both male and female clinicians.
Is the pain gap explained by women reporting more pain?
No. In the 2024 PNAS emergency department study, women were less likely to receive pain medication at every single pain score, not merely on average. Women and men reporting the identical level of pain still received different treatment, which points to how the report is received rather than how it is given.
Were women excluded from medical research?
Largely, yes. A 1977 FDA guidance excluded women of reproductive potential from Phase 1 and early Phase 2 drug trials in the United States unless they had a life-threatening condition, and it was interpreted broadly enough to exclude nearly all premenopausal women. The FDA reversed that guidance in 1993, the same year the NIH Revitalization Act required the inclusion of women in NIH-funded research. Decades of foundational research on pain, drug response and physiology was conducted in a study population that skewed heavily male, with sex differences rarely analyzed, and then applied to all patients.
Are outcomes worse for women having a heart attack?
A study of 384,878 heart attack admissions between 1994 and 1998 found that among patients under fifty, women's in-hospital mortality was more than twice that of men the same age. The gap narrowed with age and was not significant in patients over 74. Separately, the YOUNG-MI registry of 2,097 heart attack patients aged fifty and under, treated between 2000 and 2016, found women were less likely to be discharged on aspirin, beta blockers, ACE inhibitors or ARBs, and statins, and less likely to undergo coronary angiography and revascularization.
What can I say if my doctor blames a physical symptom on stress?
You can redirect the conversation out loud: "I would like this looked at as a physical symptom first. If we rule that out, I am open to talking about stress." Asking what specifically is being ruled out, and how, turns a vague plan to keep an eye on it into an actual workup.
Resources and research mentioned
Goldstein et al., NEJM 1998, sildenafil pivotal trials: nejm.org
FDA sildenafil label: accessdata.fda.gov
FDA flibanserin (Addyi) label: accessdata.fda.gov
FDA bremelanotide (Vyleesi) label: accessdata.fda.gov
Jaspers et al., JAMA Internal Medicine 2016, flibanserin meta-analysis: PubMed
Hastings Center, on the eight to three count: thehastingscenter.org
Guzikevits et al., PNAS 2024, sex bias in pain management: pnas.org
Calderone, Sex Roles 1990, bypass patients and pain medication: Springer
Vaccarino et al., NEJM 1999, heart attack mortality under 50: PubMed
YOUNG-MI registry: acc.org
AAMC, why we know so little about women's health: aamc.org
The Pink Pill documentary: announcement
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About Dr. Siân West
Dr. Siân West is a board-certified OB-GYN and menopause specialist. She hosts This Meno Life, a weekly podcast for women in midlife that covers perimenopause, menopause and MHT with the evidence first and no fear tactics.
Follow This Meno Life on Apple Podcasts, Spotify or YouTube so the next episode finds you.
I'm a doctor, but not your doctor. Everything here is for education, not medical advice. Stay curious, stay evidence-based, and always talk to your clinician before making changes.
