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The medicalisation of sex

By Maya Indira Ganesh

Science, sex and the market form a cosy mAcnage-a-trois today. Biomedical knowledge, practices and techniques have taken sexuality from the most private hidden spaces to the centrestage of international conferences. The medicalisation of sex makes a cure that comes in a foil strip far more seductive than an overhaul of a lifestyle, personality, family system or state policy

Sex in 2003 -- the act and the psyche behind it -- is re-mixed and quick-fixed, onlined and mainlined like never before. The divisions between wo/man, sex/uality, and ab/normal seem to have been smudged away. The media would collapse without it. Humour seems impossible without it. Anything can sell with just the suggestion of sex. When and how did we become so welcoming of it? Perhaps through articulation, confession, and analysis sexuality became more corporeal, less metaphorical; perhaps in its being written on the body more stridently; perhaps with phone sex, cyber sex, and latex.

But none of this is new, merely history going around in a cycle. A scant hundred years ago in the grip of Victorian Puritanism, men pranced around in tights and pancake, 'mad' women's therapy was the excision of their sexual organs and ice water baths, and piano legs were covered to prevent any suggestion of sexual arousal. Indeed, sex was a hot subject in fin-de-siecle Europe and perhaps nowhere more so than in Vienna. Contrary to popular knowledge, the most famous sexpert in those days was not Sigmund Freud, but Richard von Krafft-Ebing (1840-1902), whose fame rests on his book, Psychopathia Sexualis, first published in 1886. This work went through many editions in German and eventually became an international bestseller. It's easy to see why. It was the first modern pornographic tract successfully merchandised as medical science, a feat accomplished largely by lacing the text with Latin words. In the Preface to the Twelfth Edition of Psychopathia Sexualis, Krafft-Ebing explained: "The number of technical terms has been increased, and the Latin language is more frequently made use of than in the former editions." According to Thomas Szasz, an eminently reliable critic of psychology and psychiatry: "The medical mask succeeded in transforming the voyeurism to which Krafft-Ebing was pandering from a sexual perversion into scientific compassion." (Szasz, 2000)

Not surprisingly the technique worked like a charm. The public continued to devour this non-pictorial precursor of Playboy. For the first time in history, Psychopathia Sexualis offered people a catalogue of the countless ways -- other than the missionary position in heterosexual intercourse -- in which human beings could extract sexual pleasure from their bodies. Prior to the publication of Psychopathia Sexualis, out of the ordinary sexual acts were, literally, 'unspeakable abominations', shoved under the carpet of human consciousness as bestial, unnatural, sinful, even criminal. This meant that the law, and hence society, could not turn its back on what were then -- in a conflation of sin and sickness -- called 'perversions'. Szasz continues, saying that this modern concern with sexual medicine indicates that sex was not related to the self. With the rise of science from the 17th century onwards physicians began to displace priests as the experts on sexual behaviour, using disease instead of sin as their symbol of control (Menander).

Since the 19th century, scientific discoveries have been comfortably extrapolated into sexuality. When gaslights were installed in theatres, evening shows were when couples, hitherto restricted by the mores of the day, could indulge in petting and cuddling within a wholly legitimate social excursion. Without the vulcanisation of rubber, there would be no condoms. Without the VCR, VCD, DVD, or the Internet pornography would not be as accessible as it is. Hormone research made oral contraceptives possible. Geneticists have discovered that a gene might be at the root of homosexuality. Pharmacologists testing a medication called sildanefil citrate found that it also created erections in their old male volunteers; thus Viagra was born. Very soon there could be a similar pill for anorgasmia, a trendy term for what used to be called frigidity. And so on. Science has made deep inroads into our most intimate moments, and now with greater design and intent.

Thus sexuality was raised from the most private hidden spaces to the centrestage of international conferences. Thus sexuality was quantified in millions of dollars by pharmacology, and sexuality became the problem and the answer to every modern malaise.

According to philosopher Michel Foucault, the East has a view of sexuality as an art - ars erotica - where sex is seen as an art and a special experience and not something dirty and shameful. It is something to be kept secret, but only because of the view that it would lose its power and its pleasure if spoken about. In Western society, on the other hand, something completely different has been created, what Foucault calls scientia sexualis, the science of sexuality. It is based on a phenomenon diametrically opposed to ars erotica: the confession. Not the Christian confession, but more generally the urge to talk about it, a fixation with finding out the 'truth' about sexuality. In confessing, sexuality becomes an object of scientific investigation.

This game of you-tell-me-yours is reflective of an entire discourse around answer-seeking, proof and explanation, reflective of Western industrialised society's love affair with the scientific method - to the detriment of our sexuality. With this perspective, sexuality is reduced to sex, because it is these bodily genitalic acts that are the most tangible, the most measurable aspects of a largely intangible experience. So by breaking sexuality down into these analysable parts, the immense impact of culture, emotion and history on our desires is missed.

Alongside Krafft-Ebing was psychoanalysis, which wove much more than Greek myth into how we think about our deepest relationships, and more than revolutionary techniques to get to the elusive Mind. Like all other scientific quests it set up a system of language that persists today in naming what we feel, what we do, who we are. This is sometimes helpful, but when it comes to the vast underbelly of sex, to what causes distress, to what is too private or too complex, labels and diagnoses are the pristine tablecloths that cloak these offensive legs. Foucault (1978) says that the entire sexual lexicon becomes carefully administered and managed by select groups in positions of social, political, economic and cultural power. They erect boundaries that demarcate the reigning morality. Any expression that ventures into the fringes is immediately slapped with the label of subversion, or worse, abnormality.

A recent example of this comes from the American reincarnation of Krafft-Ebing as Masters and Johnson. In their study of human sexuality the duo operated according to a model of sexuality based on a linear point-to-point system: arousal leading to orgasm leading to plateau. This model has been criticised because it is essentially based on an arbitrary, medical, procreation-driven notion of sex. It doesn't take much to see that it also mirrors a male sexual response cycle, and this is considered scientifically 'normative'. Based purely on these physiological responses they set out to evaluate women's sexual responses. Their findings were met with opposition and outrage from feminist pockets in psychology and psychiatry. The good doctors had assumed a false equivalency between men's and women's sexual response cycles, and failed to acknowledge the role of culture in constructing women's sexuality. (Kaschak & Tiefer, 2001)

Kaschak and Tiefer (2001) say that women's sexuality cannot be conflated with the male pattern of desire, arousal, and orgasm. But that is exactly what Masters and Johnson did in their damning tome. Thus setting up a narrow field within which all women were expected to perform sexually. So if a woman did not 'achieve' an adequate (meaning measurable) level of sexual desire, was she abnormal? If she found heterosexual intercourse painful, or just didn't care for it too much but enjoyed some other activity instead, was there something wrong with her? Notions of sexual performance based on the 'goal' of 'successful' penile-vaginal penetration smacks of part scientific phallusy, part adolescent fantasy, part porn's enduring appeal. And all of it packaged as respectable medical investigation.

What is in fact 'abnormal' is the constriction of the most limitless canvas of self-expression and intimacy to the "insert Tab A into Slot B" approach (McCormick, 1994). But it is almost expected that sexuality would be confused with sex: to study bodily physical acts is so much easier, so much more the preserve of the doctor-scientist, than to delve into vague intangibles like culture or subjectivity.

Given this history, now in the Millennium of Sex it is hardly surprising that science, sex, and the market -- that heady new thing on the block -- form a cosy ménage-a-trois. Now, biomedical knowledge, practices and techniques have found their way into people's daily lives, labeling more and more of social life as 'illness' or 'disease', be it urban stress or post-natal depression. The boundaries of ab/normalcy become increasingly defined and strident, and with it the desire to be on the right side. So the promise of a cure that comes in a foil strip is far more seductive than having to overhaul a lifestyle, a personality, a family system or a state policy.

The idea that pharmaceutical companies market diseases as well as drugs is not a new one, having been historically documented by the work of David Healy. Healy describes how in the 1950s 'depression' was considered a very rare condition, affecting only about 0.01% of the population, best treated using Electro Convulsive Therapy and as an inpatient. When handy little uppers were legally launched in 1961, Merck bought and distributed 50,000 copies of Frank Ayd's book Recognizing the Depressed Patient. Three decades later the diagnostic category of depression has grown to encompass more than 10% of the population, who are usually treated with 'antidepressants' in a primary care setting.

In June 2003 the New York Times reported that for Pfizer to meet its target profits of $54B in 2004, the company had to introduce five or six new drugs annually that could each generate $1B in sales each year. This requires that Pfizer create huge markets for blockbuster drugs. The same emphasis on anti-retrovirals for protecting women from HIV/AIDS, or better female-controlled contraceptives does not seem to form part of their business plan.

This marketing of diseases has become almost inevitable as an unintended consequence of the pharmaceutical regulatory framework established in the wake of the thalidomide disaster. Over recent decades, new drugs have typically been licensed only for the treatment of specific diseases, which means that promoting new treatments will often mean promoting new diseases. Because therapeutically powerful drugs are generally available only on prescription, treatment is conditional upon receiving a diagnosis. When doctors are responsible for deciding who gets a drug, it creates the moral problem of what and when it is justifiable to treat.

More recently sexual 'problems' have also been placed under medical jurisdiction, from infertility, to now, sexual dysfunction. 'Treatments' for sexual dysfunction from Viagra to hand-held clitoral pumps signal a shift away from psychotherapy to pharmacology (Fishman and Mamo, 2001). What this does in effect is suggest that the solution to sexual problems is just a prescription away. This poses a hazard for women, given that there is an absence of qualitatively rich and culturally sensitive maps of female sexuality created by women themselves. So what constitutes 'a problem' is left to the discretion of self-help books, problem pages, male partners, and doctors. In the last couple of years pharmaceutical firms are in a race to develop a drug for female sexual dysfunction (FSD), another scientific term for just about any sexual problem women face. Like Viagra, the FSD drug should allow women to enjoy 'normal' sexual activity, assuming that everyone experiences 'normal' in the very same way. In Asia women's sexuality is either silent or controlled, and their access to health care is dependent on a complex network of family and male authorisation, physical access, and social constructions of sexual and reproductive disease. History has shown that if there are not enough checks and balances in the system, as is usually the case, drugs are dumped in the third world without adequate trials; and it's everyday women who are caught in the crossfire between the government, pharmaceutical firms, and health reform movements.

The HIV/AIDS epidemic too faces the fallout of this bio-medicalisation of sex and sexuality. Preventive efforts push condom use despite men's continued distaste for them. And there is too much rhetoric on masculinity and male sexuality as it should be rather than as it is. There is hardly enough research or interventions on sexuality, and far too much on sex as a measurable counting exercise - who in what positions and which proclivities, with little mention of the conflicts of subjectivity, desire or gender. Here too the race for a vaccine and better drugs is on. Perhaps one day children will be inoculated against HIV as they are for TB or diphtheria, allowing them to grow up imbibing the same sexual and cultural mores that encourage sexual violence, disrespect, and disempowerment.

The high priests of sex are not the ones who represent it or do it, but those who profess to understand it, or who have the means to articulate it: from agony aunts to psychiatrists to sexologists to doctors. When in doubt we don't turn to MTV's Love Line, but to those of us who wield the triple wands of ism, ology and isation to cut through the pain of pleasure.

References

  1. Charlton, B.: Psychiatry and the human condition. Radcliffe Medical Press: Oxford, 2000
  2. Fishman, J.R. and Mamo, L: Whats in a Disorder: A Cultural Analysis of Medical and Pharmaceutical Constructions of Male and Female Sexual Dysfunction in A New View of Women's Sexual Problems by Ellyn Kaschak and Leonore Tiefer (Editors), Haworth Press Inc, 2001.
  3. Foucault, M: The History of Sexuality: An Introduction (Volume 1), Penguin Books 1990.
  4. Healy, D.: The antidepressant era, Harvard University Press: Cambridge, MA, 1997
  5. Healy, D: The creation of psychopharmacology. Harvard University Press: Cambridge, MA, USA. 2002
  6. Kaschak, E. and Tiefer, L. (Eds): A New View of Women's Sexual Problems, New York, Haworth Press, 2001
  7. Klein, M: The History and Future of Sex.
  8. McCormick, N.B. (1994): Sexual Salvation: Affirming women's sexual rights and pleasures. Connecticut: Praeger in A New View of Women's Sexual Problems by Ellyn Kaschak and Leonore Tiefer (Editors), Haworth Press Inc, 2001.
  9. New York Times, June 19, 2003

(Maya Indira Ganesh writes on issues related to gender and health. She has been associated with several organisations working with gender, sexuality, child sexual abuse and domestic violence)

InfoChange News & Features, October 2003