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DISORDER MADE TO ORDER: FEMALE SEXUAL DYSFUNCTION? From time immemorial men have been grumbling about the regular mood changes that many women experience. Most of these guys were grumbling, “she’s about to have her period.” But they did not conclude that we go regularly insane. Not until someone came up with a diagnosis: Premenstrual Dysphoric Disorder (PMDD), and the pharmaceutical company Eli Lilly & Co. seriously promoted Prozac as a psychotropic that would “improve” the symptoms of women with PMDD. In June of 1999, when their patent on Prozac was about to expire, Eli Lilly & Co. began to look for ways to persuade the American Psychiatric Association (APA) that PMDD belonged in their diagnostic manual as a genuine mental disorder. Their marketing folks had designed a snappy new feminine name for Prozac – Sarafem. Getting Prozac approved for a new and different “mental disorder” would give new life to the patent – but first Lilly needed to prove that PMDD actually existed. None of the Lilly staffers (male or female) paid any attention to a brilliant 1992 study, in which researcher Sheryle Gallant and her associates took the entire symptom list for PMDD and asked three groups of people to document every day for two months the symptoms they experienced. The groups were women who reported severe premenstrual problems, women who reported no such difficulty, and men. The answers did not differ significantly among the three groups. In 2001 television commercials and magazine ads began informing us that women go crazy once a month: we don’t become irritable or unruly or fractious and crave chocolate, but we become mentally ill and need to be treated with the drug Sarafem. Voila! The APA, Eli Lilly (and other pharmaceutical companies), the media, and a few women (who sometimes feel frightened or unheard or upset – and long for respect for those feelings) had created a new medical condition. The problem with PMDD lies in pathologizing the experience of women who complain of severe premenstrual emotional problems; taking a normal, if upsetting, set of symptoms and defining them as an abnormal disease. I’ve found that women with severe pre-menstrual difficulties are significantly more likely than other women to be in difficult life situations, such as being abused at home or mistreated at work. Diagnosing their genuine challenges as a psychiatric disorder hides the real sources for much of their trouble. Fast forward a few years to 2003, when Dr. Rosemary Basson, generously funded by Pfizer Pharmaceuticals, began promoting what she calls a “new model” of disorder that will require expensive drugs to cure or treat – female sexual dysfunction (FSD). Basson cheerfully suggests that 43% of women suffer from this condition. “If they truly have no interest in sex, yes, you could say they have a disorder,” she insists. Out goes lack of passion as a motivation for abstinence, in comes a lucrative diagnosis for a medical condition that she compares to appendicitis or a broken leg.
It seems that Dr. Basson is targeting psychiatric disorder definitions for wholesale revision. Is she using the drug industry to understand women? Or do those who pay the piper call the tunes? Is a dearth of satisfying sexual intimacy being recognized, or is modern life being fashioned into a disorder? “Diseases are not just out there in nature,” says Dr. Richard Smith, the editor of the British Medical Journal, who questions the very existence of many industry-backed dysfunctions. “They are creations in many ways, and where you draw the boundaries, and what you define as a disorder, is a very tricky business indeed.” These boundaries that Basson (and behind her the pharmaceutical companies) challenges are some of psychiatry’s most authoritative, thrashed out over decades of debate. The APA’s diagnostic manual recognizes a condition called “hypoactive sexual desire disorder,” (HSDD), a “deficiency or absence of sexual fantasies and desire for sexual activity.” This might sound similar to what Basson is describing, but, as so often, the devil is in the detail. How many women on any given night might be more interested in non-sexual than sexual activity? Is this “normal?” Sex therapists recognize HSDD as being both puzzling and difficult to treat, because couples often have different levels of desire. I frequently work with women, and sometimes men, who complain that their sex drive does not “keep up” with their partner’s level of desire. Sometimes I get calls from women who are being labeled “frigid” by their angry partners, or who see themselves that way. As a clinician I throw out the disorder labels because they are not useful. Instead I help couples bridge the desire gap that sometimes looms between them. People contact marital therapists like me because they’re having relationship challenges. The World Health Organization definition of sexual problems includes a crucial prerequisite - they must be “unable to participate in a sexual relationship as they would wish.” Seems reasonable, don’t you think? But these criteria will be dumped if Basson and her pharmaceutical cronies have their way. In place of the requirement that a client must complain of being unable
to participate, they want to substitute a “scale of distress” fashioned after the grandly named International Index of Erectile Function. Since FSD is all about being female, isn’t this an odd juxtaposition? But he who pays the piper at least expects to enjoy the music – and not to hear sour notes. “Industry has a narrowing effect on how we see problems through various mechanisms, all of which are to do with money,” says Amy Allina, policy director of the National Women’s Health Network, who points to many causes of unhappy sex lives that might be overlooked in drug-based research. What about anxiety, grief, stress, fatigue or boredom? And what about life with a partner you don’t like, much less want to be sexually involved with? What about lack of communication? Does Big Pharma want to pay for highlighting such topics? You’d better believe it doesn’t. They’ll continue to fund the researchers who view the world in a way that promotes disorders that require the drugs that they manufacture.
Industry’s current favorite is a dramatic rise in the numbers alleged to be sexually dysfunctional. Remember the 43% of women uninterested in sex? This figure was derived from work led by paid Pfizer consultant/sociologist Edward Laumann who asked women, “During the past 12 months, has there ever been a period of several months or more when you lacked interest in having sex?” Well, so what if they did? Does that label them as having FSD? Is this a basis for diagnosing a disorder? If a woman isn’t turned on by the man she lives with, does this really mean that she’s mentally ill? For hospital ethics committees to approve new-product trials, they must first have a disorder for the product to treat. No disease, no treatment. But if Basson’s campaign to change definitions succeeds, sexual interest disorder will become a bona-fide problem to which remedies may be properly addressed. I shudder to consider the implications. To assume that women’s sex lives need medicating is to ignore the hundred and one other things that effect good sex. Psychologist Sandra Leiblum makes eloquent sense in the introduction to the book she co-wrote with Judith Sachs, Getting the Sex You Want. “While the search is on for a miracle potion or fail-proof device that will transform sex and make it magical, it is my belief that, ultimately, women hold the tools necessary to get the sex they want. It is their willingness to do what needs to be done – whether it means taking hormones, starting therapy, or believing that they are entitled to sexual pleasure.” It takes courage for women to confront their sexual dissatisfaction. And courage doesn’t come in bottles, capsules, or tablets. -Jill Denton is a Licensed Marital and Sex Therapist practicing in Los Osos. She specializes in helping people repair and strengthen their intimate relationships.
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