Education and debate

Sexual behaviour and its medicalisation: in sickness and in health

Graham Hart, professor ^a, Kaye Wellings, director ^b. 

^a MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow G12 8RZ, ^b Centre for Sexual Health Research, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT

Correspondence to: G Hart g.hart{at}msoc.mrc.gla.ac.uk

Religion used to define morally acceptable conduct, then doctors became interested in sexual behaviour. Now we live in a world where celibacy is the new deviance, and surgery and drugs are used to enhance sexual pleasure. Graham Hart and Kaye Wellings reflect on the extent and consequences of the medicalisation of sexual behaviour

"Sex survey ruined our wedding," screamed the front page of the Sun.¹ The newspaper reported how a "couple had a furious row and called off their wedding after the bride-to-be revealed their sex secrets in a university survey." This could be a routine example of how the press uses research on sex to sell papers. This case is more interesting, however, because the groom to be was clearly unhappy with the extent of sexual surveillance, which arguably is a feature of the medicalisation of sexual behaviour in British society. To what extent has there been a medicalisation of sex, and what are the consequences of this?

	Medical authority and sexual behaviour

The exercise of medical authority over sexual behaviour has a long history. Religion once defined morally acceptable sexual conduct, but in an increasingly secular society, this task fell to medical science. In the latter half of the 19th century, medical professionals became interested in behavioural domains previously the preserve of religious authorities and moralistscriminality, alcohol and drugs, and sex.^2-4 Although Philip Larkin would have us believe that "sexual intercourse began in nineteen sixty-three,"⁵ the taxonomy by which sexual behaviour is defined was invented a century earlier, when a new breed of sexologists created diagnostic categories such as homosexual and heterosexual, hysteria and nymphomania, and a host of arcane paraphilias.⁶ These labels served to define what was normal and acceptable and what was not, distinguishing "perversions" from "acceptable" heterosexual, procreative, and monogamous sex.

The long tradition of representing illness as a punishment for sin was continued when sexual behaviour was medicalised and transformed into morbidity.⁷ Some doctors described in detail the supposed adverse outcomes of sexual acts to deter the practice of these acts (figs 1 and 2). In the mid-19th century, William Acton prescribed against masturbation (fig 3). He invented a condition that he called "spermatorrhoea" (box 1), which left generations of boys and young men with the injunction that manly youth "should be accompanied by complete repose of the generative [sexual] functions, unbroken by anything like intense feeling for their employment."⁸

	Doctors and discussion of sexual behaviour

Acton was a doctor and could be explicit about sexual behaviour, but by daring to pay any attention to sex, he was rare in the profession.⁹ Others, such as Havelock Ellisalso medically qualified¹⁰followed, but the open discussion of sexuality and sexual behaviour in Britain in the late 19th and early 20th centuries was led not by "medical men" but by other liberal intellectuals. These included Edward Carpentersocialist writer and admirer of muscular working men⁶and Marie Stopesthe great publicist for contraception (for married women) and writer on sex (in marriage)who was a botanist.¹⁰ Alfred Kinseythe American expert on sexual behaviour in the 1940s and '50strained as an entomologist.

(Credit: NATIONAL LIBRARY OF MEDICINE) Fig 1.   Facial effects of masturbation. From Boyhood's perils and manhood's curse, 1858

(Credit: NATIONAL LIBRARY OF MEDICINE) Fig 2.   Device to discourage masturbation. From Considération sur les hernies, Paris

Until the mid-20th century, the number of doctors who wrote about sex was small.¹¹ The fact that few medically qualified doctors provided historical accounts of sexual behaviour does not mean, however, that medicalisation had not occurred. If medicalisation is seen as a social process that does not require the active involvement of doctors, and medical science is invoked to support particular ideological positions, then the medicalisation thesis can be sustained regardless of the number of doctors involved.

	Psychiatry and the medicalisation of sex

Psychiatry, as the moral arm of medicine, played a major role in developing the idea that some sexual behaviours are expressions of disease. The Diagnostic and Statistical Manual of Mental Disorders, first published by the American Psychiatric Society in 1952, described "treatable" behaviours that previously had been seen as morally inadmissible. This book was hugely influential in defining and sustaining judgments regarding the sexual behaviours that required medical intervention.¹² For example, homosexuals, formerly considered to be sinners, were labelled as illnot bad, but mad. Commitments to mental institutions, hormonal treatments, and castrations were used to deal with unwanted sexual behaviour. This process has taken a new form recently, with the search for the "gay gene" and the continuing refusal of some to see sexual expression as historically variable and socially constructed. ^{13 16}

(Credit: NATIONAL LIBRARY OF MEDICINE) Fig 3.   William Acton, 1813-1875

In the years before the second world war, pregnant, unmarried young women could still be sent to and indefinitely detained in psychiatric institutions. Treatments for homosexual mensuch as aversion therapycontinued until, and beyond, 1973, when the American Psychiatric Association redesignated homosexuality as non-pathological. Even venereology (later genitourinary medicine)the specialty specifically responsible for treating sexually transmitted infectionswas marked throughout the 20th century by an uneasy truce between medical moralists and those promoting practical public health measures to prevent infection.¹⁴ R C L Batchelor, Physician in Charge of Edinburgh's venereal disease services until 1954, often described people who transmitted infections as "moral defectives" who should be confined.¹⁵

	Men, women, and sexual behaviour

A marked distinction has existed with respect to the perceived responsibility of men and women for sexual healthwomen consistently have been seen as "reservoirs of infection." In 1962, health promotion materials that targeted men could say that "a girl may be perfectly clean . . . and yet have in her body millions of the invisible germs of gonorrhoea or syphilis, or perhaps both."¹⁵ Even in the late 20th century, the United Kingdom's proposed national screening programme for Chlamydia trachomatis suggested that only women be tested.¹⁶

	A new era for sexual attitudes

The latter half of the 20th century saw major changes in sexual attitudes and mores. We no longer look on sex not for procreation as sinful. This change in attitude has been accompanied by greater acceptance of the diversity of human relations. The shift in perspective has been dramatic, and it means that variations within and between heterosexual and homosexual desire have becometo a greater extent than ever beforea matter of choice. For some religious stalwarts, sex is still acceptable only as a procreative activity within marriage; for others, it's OK to be homosexual but not to practise same sex activities. Generally, however, people increasingly accept diverse sexual expression.¹⁷

The trend towards accepting that sexual congress is not exclusively for reproduction, but is part of healthy human interactions and relations has, with a few exceptions and provisos, been furthered by the medical profession. Therapeutic discoveries have removed many of the adverse outcomes of sexual behaviour. Medical treatments and interventions have saved thousands of lives and prevented significant morbidity resulting from sexual behaviour:

• Antibiotics for bacterial infections

• Vaccination to prevent viral infections

• Antiviral and antiretroviral treatments for herpes simplex virus-2 and HIV.

The development of the contraceptive pill freed women from the fear and reality of unwanted pregnancies, despite its side effects. Marksin her history of the pillrefers to women for whom this was "a dream come true."¹⁸ Even critics of the pill cannot deny the massive social changes intimately connected with the widespread availability in the late 20th century of this chemically based contraception for women.

	Mass surveillance, regulation, and control

The philosopher Michel Foucault and his followers warned that liberalisation of sex, open discussion about sex, and more importantly the detailed scientific description of its parameters and correlates may just be part of a continuing modern project of regulation and control.¹⁹ According to this view, various works across the years have simply been ever more rigorous and systematic variations of the surveillance of sexual behaviour by the state and other disciplinary institutions (box 2). For followers of Foucault, the "clinical gaze" (a generally medicalised perspective on the world) transforms this surveillance into control over sexuality, both in the populationthrough public health mechanismsand (ideally) through self regulation.

Mass surveillance inadvertently establishes norms and standards for sexual behaviour against which people can measure themselves and be measured. This can bring benefitswhen Kinsey reported on the heterogeneity of sexual conduct in America, ^{20 21} Americans who had previously felt deviant gave a collective sigh of relief. There are also risks attached to such transparencymany people will feel "inadequate" when faced with evidence about extremes of sexual performance. This can turn sex into a problem"Is that normal, doctor?" From identification of the average number of times Britons have sex every month (6.4 times for men and, interestingly, 6.5 for women)²⁴ to articles in Cosmopolitan magazine on how to have better sex and achieve orgasms every time, the prescriptive boundaries of normality are pushed further, and imperatives are stated.

(Credit: WWW.DRMATLOCK.COM) Fig 4.   Does such advertising encourage sexual dissatisfaction?

	Medicalisation and sexual pleasure

Not surprisingly perhaps, the medicalisation of sexual behaviour has extended most recently into the domain of sexual pleasure. Doctors are wheeled in to place sex at the centre of a healthy lifestyle, and articles peppered with physiological and technical terms confirm and elaborate on the right way to perform "to please him or her." Men and women are encouraged to protract their sexually active lives, regardless of desire. Viagra (sildenafil citrate)the first oral drug to treat impotence, or erectile dysfunctionranks as one of the greatest success stories in pharmaceutical history. When it was launched in 1998, it became the world's most popular medicinal drug ever, outselling even fluoxetine (Prozac). Although Viagra is not yet approved for women by the US Food and Drug Administration, studies are evaluating its effects in women with arousal problems.

Gynaecological surgery is also being harnessed to enhance female sexual pleasure and improve aesthetics (fig 4). So far, genital enhancementthe so called "designer vagina"has had little impact in the United Kingdom, but it is routinely advertised in America. Procedures include:

• Liposuction of oversized vulvas

• Labiaplasty to "aesthetically modify" the labia

• Clitoral repositioning

• Tightening of vaginal muscles and support tissues

• Reduction by laser of redundant vaginal mucosa.

Some of these procedures grew out of traditional gynaecological surgery for urinary incontinence and episiotomiesthe "extra stitch for the husband" familiar to gynaecologists. Laser pruning of unsightly or unsatisfying genital morphology is now carried out, however, expressly for sexual gratification.

Fig 5.   Furthering the "tyranny of genital sexuality"?

The application of medicine has considerable scope in this context (fig 5). In America, erectile dysfunction is estimated to affect 50% of men aged 40-70 and 70% of men >70 years. ^{27 28} Thirty one per cent of American men and 43% of American women have reportedly had sexual dysfunction at some time in their lives.²⁹ These estimates explain, in part, the stampede to obtain Viagra. Yet whether people seek medical treatment is associated not only with the scale of a problem, but also with its perceived severity and the opportunities for treatment. The high prevalence of sexual dysfunction reflects the escalating sexualisation of our cultureour obsession with sexual gratification has undoubtedly increased people's expectations, and it may have increased people's feelings of inadequacy. Although many men with erectile dysfunction daily thank Pfizer for their efforts, others who once thought their low libido was "normal" and acceptable now feel dissatisfied with their sexual lives.

	Overmedicalisation of sex

Relatively recently, the imperative was for restraint and moderation in sexual matters; now it is for more and better sexual gratification. We can see this as the replacement of one orthodoxy by anotheras an over-medicalisation of sex. Celibacy is the new deviance. The irony is that we may be moving away from diversity towards greater uniformity. By encouraging women to look like Playboy centrefolds and men to seek priapic perfection, we may be furthering what has been termed the "tyranny of genital sexuality."³⁰

The authors of one American report on sexual dysfunction stated that "the strong association between sexual dysfunction and improved quality of life suggests that this problem [sexual dysfunction] warrants recognition as a serious public health concern."²⁹ Yet American studies also show that many people's experiences of sexual dysfunction are associated with unsatisfying personal experiences and relationshipsthe cause of sexual dysfunction in these cases is almost certainly bidirectional.

The problem with an overly medical approach to sexual behaviour is that social and interpersonal dynamics may be ignored. People choose one another for their uniqueness. The last century saw a considerable increase in acceptance of diversity of sexual expressionit would be a shame if this century saw diversity replaced by uniform expectations of performance and desire.

	Acknowledgments

Thanks to Caroline Allen, Ray Moynihan, Mark Petticrew, Richard Smith, Daniel Wight, and Sally Macintyre for comments on drafts of this paper.

	Footnotes

Competing interests: None declared.

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