On either side of the waiting room at Vancouver's Centre for Sexual Medicine are tables loaded with industry literature - for the most part aimed at men. Questionnaires are in vogue, and I find myself scanning them, while Rosemary Basson finishes up with a patient. "Do you remember a time when you felt better about your ability to have sex?" asks GlaxoSmithKline's brochure, Intimacy, Depression and Antidepressants. "Do you find yourself falling asleep after dinner?" inquires Organon's leaflet Testosterone and Andropause.
I tear a four-by-eleven-inch quiz form from a pad that gives no clue to its publisher or printer. But I have seen it before, and even know who wrote it: psychologist Dr Raymond Rosen of New Jersey. Asking stuff like "How do you rate your confidence that you could get and keep an erection?" and "During sexual intercourse, how difficult was it to maintain your erection?" it draws me into scoring myself on a scale of 1 to 25 - with "21 or less" a reason to see the doctor.
The form looked official, perhaps from the Vancouver hospital, but it was really a crafty Pfizer sales tool. Rosen, a professor at Robert Wood Johnson Medical School in Piscataway, is a pre-eminent drug company consultant in this field - financed by Pfizer, Merck, Lilly, Bristol-Myers Squibb, Procter & Gamble and Icos - and has cornered the market in consumer surveys that lay the bedrock of industry campaigns.
But confusions are as common in the field of pharmaceuticals as they are in the world of double glazing. A Basson abstract on the Medline database, for instance, implies that a study of Viagra comes from the Vancouver hospital - while the text shows it's really from Pfizer. The grandly-named International Index of Erectile Function and the Female Sexual Function Index are merely formats for Rosen's Q&As. And the influential Consensus Development Panel on Female Sexual Dysfunction is just 19 specialists, Basson included, of whom 18 admit receipt of industry money.
Even the Paris conference wasn't quite what it seemed - at least to some of those who sat around me. Vice-chair Basson, two members of the scientific committee and various other participants all told me that the Palais des Congrés gathering was a WHO event. "It's a consultation to them, to guide them when they make their decisions," Basson explained. "Plus the financing of the consultation comes from them."
This was news to the WHO, who e-mailed me from Geneva dissociating the agency from the meeting. Although participants told me they thought that travel grants for a "faculty" of around 200 key opinion-formers (a free hotel room each and $1,700 expenses) came from the United Nations health body, the whole shebang was essentially an industry jamboree, as was the previous Paris bash four years back.
"For the 1999 conference, WHO agreed to co-sponsorship on the understanding that there were no commercial interests involved," the director-general's office told me. "We later learnt that satellite symposia [advertising segments] organised by pharmaceutical firms were included in the programme. We asked the organisers to remove this from the programme, but due to the intervening lapse of time, our records are incomplete on the follow-up to this request."
This didn't stop a 750-page colour book being published from the 1999 conference bearing the WHO crest - and I found a certain murkiness, even for pharmaceuticals, when I tried to nail down the book's status. Co-authored by Rosen, it purported to be published by "Health Publication Ltd", a company with nothing more than a Jersey, UK, post office box. Another Jersey box in the name of "Signet Media", to whom conference cheques were paid, didn't come up on the 3.3-billion-page world wide web. And the registered address of the organisers' domain was the unhelpful not @available.com.
When I raised these with Basson, she said she didn't know, but she must have felt the hand of business. The Paris events were just two of seven industry-backed gatherings in the past six years that laid the ground for the definitions she announced. The founding event, held in May 1997 at a hotel on Cape Cod, was sponsored by nine drug companies. "The meeting is completely supported by pharmaceutical companies, and half the audience will be pharmaceutical representatives," Rosen wrote to colleagues at the time. "Only investigators who have experience with, or an interest in working with the drug industry have been invited."
Basson knows the score. It's how the system works: how industry holds the ring for medical discourse. "There's not a lot of money in medicine, period, and for research in the area of sex it's just dismal," she tells me, arguing that without such support leading experts around the world would never meet face-to-face. "So what do you do? You just sit in your little clinic and you can't help anyone."
But he who pays the piper at least expects to enjoy the music - and not to hear notes of discord. "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 Washington-based National Women's Health Network, who points to the many causes of poor sex lives that may be overlooked in drug-based research.
What happens, for instance, to headaches, stress, fatigue or boredom? What about the lack of physical exercise or poor diet? And what about life with a partner you don't like, much less want to be physically involved with? Does industry want to pay for highlighting such topics? You had better believe it does not.
"Bias is very subtle," says Smith of the BMJ. "There are many more people who want to do research than receive funding, and if you have the huge resources of the pharmaceutical companies, you can say you'll fund these people and not those people because these people view the world in a way that looks good to you."
Industry's current favourite is a dramatic expansion in the numbers alleged to be dysfunctional. According to scores of scientific papers, including one with Basson's name on it, 43% of women (and 31% of men) have a sexual "dysfunction", "problem" or "complaint". And as New Jersey psychologist Dr Sandra Leiblum, who has worked with Rosen for years, told an event sponsored by 17 companies in 1999: "Especially remarkable was the finding that one out of three women said they were uninterested in sex."
Remarkable, indeed, since they didn't exactly say that - and there is no data that any complained. The figures being used to build the new market have been cribbed from work led by a Chicago sociologist, Dr Edward Laumann, (sponsored, like Rosen's medical school, by the philanthropic arm of Johnson & Johnson). But all he asked women was: "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 there was? Does that fix them as uninterested? Is that a basis for diagnosing a disorder? If a woman isn't turned on by the father of her children, does that really mean she's mentally ill? "I think we should be very suspicious of these figures," says Dr Ellen Laan, professor of clinical psychology at Amsterdam University.
Laumann's figures might have faded like a magazine sex survey, with little more reaction than "fancy that". But in 1999 his data resurfaced on the new tide of industry cash. For some reason, the otherwise prestigious Journal of the American Medical Association republished his seven-year-old research as an "original contribution", now co-authored by industry man Rosen. Two months later, the journal issued a "correction". "Since 1997," it said, "Dr Edward O Laumann has served on the Scientific Advisory Committee to Pfizer."