June 15, 2024

Healthy About Liver

Masters of Health

Amazon’s Attack on Women’s Health

Aaron Wilt’s mother and sister are physicians; as the black sheep of the family, he went to college for computer science. He found a way back into the family preoccupation with medicine, however.

Wilt’s mother suffered from an ailment known as pelvic floor dysfunction. His wife had similar issues after the birth of their children. Through research, he learned that this malady affected as many as 1 in 3 Americans, predominantly women, though many were embarrassed to discuss it.

“I talked to some of these women on the phone,” he told me. “Even in 2015, it would be rare for a woman to speak to a man on some of these issues. Women were crying to me on the phone. It was very clear that they were being underserved.”

Pelvic floor dysfunction occurs when the muscles inside the body around the pelvis are impaired. It can lead to a variety of symptoms, including urinary incontinence, chronic constipation, pelvic organ prolapse (when organs slip out of place and protrude), and persistent pain, particularly through penetration—everything from the insertion of a tampon to intercourse.

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Wilt linked up with Dr. Amanda Olson, a certified pelvic floor physical therapist in Oregon. Together they started a business called Intimate Rose, which sells a series of devices—kegel weights, pelvic wands, and vaginal dilators—designed to strengthen the muscles, train sensitive tissue, and improve patient coordination and endurance. The products were cleared and registered with the Food and Drug Administration, making them some of the only FDA-compliant devices in the field.

Affordable products that can be used at home eliminate the need for expensive physical therapy, which is usually uncovered by insurance, and reduces the awkwardness of having a therapist manipulate sensitive areas of the body. “One of the goals for physical therapy is we want the patient to be independent,” Olson said.

Intimate Rose has grown into a company with millions of dollars in annual sales, and a grateful client base. “It can change people’s lives and I am living proof of that,” said Sarah Mayer, a fitness instructor in Fort Polk North, Louisiana, who has used the products since experiencing prolapses and tears after giving birth.

“Not only does it hurt me as a business owner, but women need these products.”

But Intimate Rose stands on a precipice today, due entirely to the whims of an e-commerce leviathan that can make or break small businesses through the tiniest of decisions.

In January, Amazon will automatically recategorize Intimate Rose products into their adult section, making them invisible to general search and ineligible for on-site advertising. Whenever Amazon has periodically miscategorized Intimate Rose products as adult before, as it has during a four-year saga of competing companies’ efforts to sabotage it, the miscategorization has led to an 80 percent drop in sales, according to Wilt.

The company makes about half its sales on Amazon, and has been trying to redirect people to its own site. But even clinicians prefer to send clients to Amazon, which as the dominant e-commerce platform adds convenience, ubiquity, and a measure of trust. Funneling these clients, many of whom obtained their injuries through sexual trauma, to an explicit adult-themed mini-site that depicts medical treatments as sex toys can be triggering and stigmatizing, and lead patients to decline the products. “Not only does it hurt me as a business owner, but women need these products,” Wilt said.

The story of Intimate Rose’s platform misplacements shows how selling on Amazon, while opening businesses up to a universe of potential customers, comes with a cost: the ever-present threat that you can have your products taken down or shunted into some unseen corner. With little choice but to sign up with Amazon to reach the masses, small businesses must play by, and often get burned by, Amazon’s mercurial rules, and its light policing of a marketplace that can operate like the Wild West.

“Anti-monopoly folks have been talking for a while about tech companies being a form of private government,” said Stacy Mitchell of the Institute for Local Self-Reliance, a frequent Amazon critic. “This is a very specific way in which Amazon is effectively regulating the distribution of a medical product and affecting thousands of patients with this condition.”

UPDATE: One minute after this story posted, an Amazon spokesperson responded to a request for comment, largely reiterating what was in its public announcement. “Amazon aims to provide the best possible customer experience, which includes presenting customers with only the most relevant and appropriate search results. We’ve adjusted our policy regarding wand massagers and kegel/ben wa balls to better serve these listings only to intending customers, whether for medical or sexual health, and not in unrelated searches,” the spokesperson said.

THE PROBLEMS STARTED FOR INTIMATE ROSE fairly soon after it decided to sell on Amazon half a decade ago. “It’s been hell,” Olson said.

Amazon first made it difficult for Intimate Rose to talk to its customers, because it didn’t want communications to happen off the website. “People don’t want to discuss sensitive things on Amazon.com,” Wilt explained, but Amazon was insistent. At that point, Intimate Rose sought out a Shopify site with their own branding. But the company learned quickly that many of their customers preferred to shop on Amazon. It couldn’t abandon that marketplace.

Later on, the sabotage emerged, a surprisingly common occurrence that third-party sellers on Amazon have to handle. Sabotage comes in many forms, but with Intimate Rose the scheme was simple. Rival firms would attempt to have the company’s products reclassified into the adult category, often through sending emails to Amazon customer service pretending to be site users who were offended by seeing products deemed as sex toys in a simple search.

When I mentioned this gambit to Chris McCabe, a former Amazon employee who now works as a consultant for third-party sellers who have problems with their accounts, he immediately said, “That’s the third- or fourth-most common attack. Anyone that has an opportunity to push you into the adult category is going to take it.” He noted that the adult site is perfect for a competitor strike, because it puts products into a “search Siberia.”

These sophisticated attacks, using bots and fake accounts and other forms of trickery, are typically handled by hundreds of “black hat” companies that specialize in this work. “It’s all outsourced; no one does this themselves anymore if they’re serious about it,” McCabe explained. The companies hiring the black hats are often overseas and out of reach of U.S. law enforcement. Intimate Rose has engaged in lawsuits against competitors, some of which Wilt couldn’t discuss because they remain open.

Amazon does surprisingly little to prevent this abuse. Their customer-centric policy and use of algorithms to monitor the marketplace lead to a particular sensitivity to these kinds of complaints, whether they are verifiable or not. Other common attacks include inserting a back-end keyword onto a listing (like “pesticide” or “cannabis”) that will immediately get it flagged; fake copyright complaints that lead to products or images being taken down; and more recently, charges about expired products. “I’ve got somebody selling Rubbermaid (plastic containers) being told this is expired,” McCabe said.

Amazon offers a service called Brand Registry intended to protect brands on the site. But Intimate Rose is signed up for Brand Registry, and despite that has had nonstop problems. “Brand Registry protects you from infringement and copyright, it does not protect you against hacks,” said Paul Rafelson, executive director of the Online Merchants Guild, a coalition of third-party sellers. “It doesn’t do a great job on infringement, either.”

FENDING OFF THESE ATTACKS has become a novel and resource-intensive hassle associated with selling on Amazon—a challenge no offline business has to deal with. Wilt told me he has two full-time staffers whose entire job consists of putting out fires on Amazon. The biggest challenge is to get Amazon to reverse its decisions when it miscategorizes their products.

“We would have to go through a whole ton of fiery hoops,” Wilt said. On a Zoom call, he showed me his team’s project management software, which tracks every case they’ve had with Amazon, including every phone call, email, or other communication. The list stretched on for pages and pages. The company keeps all the data as a repository and handbook for what to do when another attack hits. As a case study, we looked at a suspension of kegel weight products from May. “This was a good outcome, it only took 15 days to get back up,” Wilt said.

Often, the appeals go first to Amazon’s frontline seller support system, which is staffed by overseas contractors with different cultural understandings, whom Wilt found indifferent to appeals about vaginal wands and kegel weights. (“The brand is called Intimate Rose, but if you’re from overseas you might read it as ‘intimate: rose pelvic floor weights,’” Wilt explained.)

Cases can escalate to Amazon’s catalog and captive teams, both of which can see but not flip settings to take a product out of the adult store. The restrictive products team can, but Wilt told me that the catalog team cannot phone the restrictive products team, and can only communicate with it through email. Another level goes to the seller performance team, which is powerful but very ring-fenced. “People in Seattle have told me, ‘I would like to help but I have no contact,’” Wilt said.

It’s all incredibly debilitating, Wilt explained. “To get a successful resolution, the person [whom Amazon has assigned to rule on appeals] has to read the policy, understand the policy, look at the product and understand the product,” he said. “It’s hard to get all four to line up.”

Moreover, all of these teams are judged on their performance based on the number of cases they can close per hour, and often do the bare minimum to get cases off their plate. Every time a case gets closed, Wilt’s team tries to open it back up again. Sometimes Amazon puts a “close and do not reopen” option on the cases.

Sabotage comes in many forms, but with Intimate Rose the scheme was simple. Rival firms would attempt to have the company’s products reclassified into the adult category.

After exhausting all avenues, the last chance is to escalate to top Amazon executives. It was common for sellers to send an email to Jeff Bezos, when he was CEO, begging him to get their product off suspension or get it restored. (Bezos doesn’t read the emails, but an executive seller relations team does, and works on cases.) At one point, Wilt’s team started hitting up Amazon executives on Twitter, including Dharmesh Mehta, vice president of worldwide customer trust and partner support. That worked for a while until he ghosted them.

The final resolution of Intimate Rose’s appeals came on October 1. In a bulletin to all sellers—there was never a communication about this to Intimate Rose directly, and Wilt found out about it from a friend—Amazon stated that, beginning November 15, all “wand massagers” and “kegel/ben wa balls” would be automatically classified as adult products. The announcement stated that this was “meant to prevent adult products from being surfaced to customers who are not intending to find these types of products while shopping on Amazon.”

Wilt showed me a chart laying out what has happened in the past when Intimate Rose products have been categorized as adult. Their seller rank falls precipitously, sometimes to the point that tracking software literally cannot find the products on Amazon. After it’s resolved, it takes effort and money to get the seller rank back up, through flurries of advertising pushing their products. “It’s like a snowball: When it’s good, it has momentum, but when things start to melt, they melt fast,” said Wilt.

Upon learning of Amazon’s ruling, Intimate Rose jumped into action, getting over 70,000 people to sign a Change.org petition asking Amazon to properly label its FDA-compliant devices. “We deserve the right to safely and conveniently locate medical devices without unnecessary exposure to sexually explicit products,” the petition reads.

On November 7, Amazon issued an update to their original policy. To give “more time to prepare for this change,” Amazon shifted the effective date to January 17, 2022. Amazon also said the products would be discoverable within a listing category like “health care,” just not in a general search. The announcement said that Amazon was striving for consistency in how to categorize the products so they are not “surfaced to children or other unintended audiences,” and added something written seemingly with Intimate Rose in mind: that the products would be categorized this way “regardless of whether they are for medical use or not.”

THE PROSPECT TALKED TO SEVERAL CLINICIANS and customers who use Intimate Rose products to ask about the effect of moving the products into Amazon’s adult category. They uniformly characterized it as both devastating and offensive.

“I worry about my own patients,” said Sonia Bahlani, who treats pelvic pain in New York. She explained that the stigma associated with the issue makes it hard for patients to seek help, estimating that on average, from the onset of symptoms to actually seeking care can take seven to eight years. “To add another gateway where it’s going to be harder for them, we’re looking at a time lapse, suffering in pain for longer time,” she said. “It means it stops momentum in seeking care.”

Delays in care for pelvic floor dysfunction can also make it harder to treat. And the pain can be debilitating. Kim Vopni, the self-described “Vagina Coach” who teaches and works with clients at her website, stressed that the ailments can lead to isolation and depression. “People will avoid social interactions with friends, won’t leave their homes, stop participating in exercise, stop engaging in intimate relations,” she said.

Jennifer Morgan with Centrality Physical Therapy and Wellness in Connecticut sends some clients to Amazon for Intimate Rose products. “Amazon makes things discreet and convenient, where they don’t have to add an additional filter,” she said. She focused on the shame patients would feel from having to go to adult websites to get medical devices for relief for their condition. Many women experiencing pelvic floor dysfunction “have a history of sexual abuse or trauma,” Morgan pointed out. Pushing them to an adult website where their pain-relieving medical device is listed next to sex toys with explicit imagery can be triggering.

“From a clinician’s standpoint helping to run the business, I’ve been working for a decade to destigmatize pelvic health,” said Dr. Olson of Intimate Rose. “To help people not be uncomfortable. For this to happen, it’s shoving people back.”

Categorizing pelvic floor products as adult can break the level of trust clinicians have to build with clients, Vopni said. “We see messages that light bladder leakage is just part of being a woman. The taboo, shame, embarrassment, ignoring from care providers, and media messages that it’s something to accept as normal are reasons why people don’t seek help.”

Categorizing pelvic floor products as adult can break the level of trust clinicians have to build with clients.

Intimate Rose testimonials are overflowing with support from women who struggled with vaginal pain for years. Sarah Mayer is one such user with a harrowing story. She had a difficult birth of her first child that caused a severe pelvic tear. The wound after delivery required over 200 stitches, and left her with a hole in her perineum and a prolapse in the uterus.

“When trauma like that happens to the body, you don’t want to go down there,” she told me. “It took months to think about being with my husband or using a tampon. Everything was extremely traumatizing. At the physical therapist, my body would convulse on the table.”

Mayer uses Intimate Rose dilators and wands, and described the products as “essential.” She was paying out of pocket for physical therapy, as pelvic floor dysfunction was not covered by her insurance. Getting a low-cost tool to use at home to break up scar tissue and ease out knots was a huge financial and mental relief.

“For me, I find it extremely offensive for Amazon to label them as sex toys,” Mayer said. “Sex toys are supposed to be pleasurable but there is nothing pleasurable about this.” She had purchased one of her products on Amazon and said she would definitely have been discouraged if it were labeled as a sex toy.

Mayer also noted what she considered an obvious gender bias at work. “It blows my mind,” she said, “that men can have incontinence tools listed as medical equipment but women can’t.”

INTIMATE ROSE HAS 50 EMPLOYEES currently; if the recategorization goes through as scheduled, Wilt said that he would not be able to continue staffing levels. “The customer pays the price, the U.S.-based small-business owner pays the price,” he said.

As for why Amazon just decided to move forward with a blanket policy that classifies medical devices as sex toys, experts said this was very common. Once a product goes back and forth through misclassification enough times, it gets labeled as a problem, and it’s in Amazon’s best interest to solve it, however unsatisfying that may be for sellers and customers.

“They’re tired of dealing with it,” Chris McCabe said. “They’re spending thousands of man-hours on this stuff. It’s easier for Amazon to say, let’s just carpet-bomb, throw everything over here.”

It’s particularly notable considering that Amazon has made a major priority of violence against women and women’s health. The company has a relationship with Mary’s Place, a homeless and battered women’s shelter in Seattle; there’s even a Mary’s Place facility inside Amazon’s flagship headquarters building.

McCabe surmised that it wouldn’t even be a particularly high-level person making the decision to automatically classify adult products. The situation highlights how little attention Amazon pays to the persistent problems of its third-party sellers. “People’s lives and livelihoods and the lives of the people who rely on these products are affected by poorly thought out, shortsighted decisions,” Rafelson said. “This is a women’s health product. This is like denying women a tampon because it’s phallic.”

Mitchell, of the Institute for Local Self-Reliance, noted how Amazon personally benefits from having a frazzled set of third-party sellers under constant threat of attack. “It creates an environment in which legitimate businesses are wasting all this energy dealing with hijacked listings,” she said. “It plays into Amazon’s power. Any real threat to their power is going to come from a legitimate business.”

It also creates a kind of learned helplessness from sellers, who have little hope of navigating Amazon’s endlessly shifting private law.

“It’s just like all of our work trying to re-educate Amazon and re-educate the world just imploded,” Olson said. “It was the most bottoming feeling.”

UPDATE: The Amazon spokesperson, in a statement to the Prospect, says that “this policy change is only for wand massagers and kegel ben wa balls. Pelvic wands, like the ones that are sold by Intimate Rose, are a separate product and would not be impacted by this policy change.”

In response, Aaron Wilt said that the kegel weights product it sells was identified as “not adult” for over a year, but it was repeatedly miscategorized. “There are two overlapping issues at play,” Wilt said. “What is the policy, and what does some support rep in India think is the policy based on looking at our product and looking at the documentation… There is no way some overseas rep knows the difference between a ‘wand massager’ and a ‘pelvic wand massager.’”