Sexual behaviour and its medicalisation: in sickness and in health
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7342.896 (Published 13 April 2002) Cite this as: BMJ 2002;324:896
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Hart and Wellings' article rightly implies equal acceptance of same-
sex and male-female partnerships. It notes also the continuing presence in
some parts of society of disapproval of those who prefer a same-sex
partner.
This continuing anachronism arises from the outdated concept of
homosexuality as being a medical or psychiatric disorder,an example of
medicalisation in the profession of some decades ago, but not everyone has
caught up with the change. As A result we still have relics such as
section 28 of the Local Government Act which forbids the 'promotion' of
homosexuality in schools, and a church that prevents practising
homosexuals from being appointed as clergy. These are not just harmless
eccentricities; their effects are widespread and serious, inhibiting sex
education in schools and promoting the idea that the country's religious
leaders regard homosexuality as a deviance and not just as diversity
within the range of normality. This climate of criticism results in a
knowledge deficit which leads to the highest rates of teenage pregnancies
in Western Europe, sexually transmitted diseases, and both mental and
physical injuries from bullying of gays and lesbians. So doctors cannot
say it's not their business.
What is needed is an explicit lead from the medical profession,
particularly from informed people like the Authors,that same-sex
relationships are not disordered and are as good and as valid as
heterosexual partnerships. This is not forthcoming and I suspect the
reason is the prospect of incurring the displeasure of the homophobic
section of the community, including the Daily Telegraph and the Daily
Mail.
Competing interests: No competing interests
The subject of the medicalization of sexual behavior requires an even
larger perspective than that offered by Hart and Wellings, one
specifically identifying socioeconomic trends and agents (1). For example,
the addition of "sexual dysfunctions" to the American psychiatric
nomenclature in 1980 came at a time when psychiatry needed to become more
biological and quantitative to participate in new US insurance
reimbursement plans. The Masters and Johnson list of disorders, focusing
on dissatisfaction with genital arousal and orgasm, but omitting problems
of pleasure or intimacy, fit these quantitative/biological needs but
popularized standards for sexual satisfaction that are overly genital and
performance-oriented (2).
The involvement of urologists in male sexual problems in the 1980s
came about because of specialist needs for new topics and patients, the
encouragement of newly interested industries, and shifts in academic-
industry relations (3, 4). It was widely promoted in the press, a separate
issue in itself, creating heightened expectations about medical sexual
"expertise."
When Hart and Wellings cite epidemiological statistics for sexual
problems, they inadvertently contribute to the problems of medicalization
by citing weak research and failing to discuss how defining a problem
plays a part in market-driven medicalization. American studies of sexual
problem prevalence utilize overinclusive definitions, not surprising when
the extent of drug company involvement in the research is revealed (4, 5).
Finally, a discussion of medicalization needs to examine the fit
between models of sexuality and the medical model (6) Hart and Wellings
conclude that the problems of medicalization are really those of "over-
medicalization," but I believe that is a superficial assessment. Sexuality
is a social construction, and medicalization is the new social
construction. Excessive medicalization may be malpractice, but we must
question the fundamental model of sexuality as a biological rather than a
sociocultural and political entity. Hart and Wellings' final sentence is
their strongest, but their analysis needs to be harder hitting to make it
persuasive.
Enraged to see for-profit medicalization moving into the arena of
women's sexual problems, a new grassroots feminist campaign has emerged,
and I call the readers' attention to its website, www.fsd-alert.org, and
other activities. (7)
(1) Tiefer, L. (1995) Sex is Not a Natural Act, and other essays.
Boulder, CO: Westview Press.
(2) Tiefer, L. (1991) Historical, scientific, clinical, and feminist
criticisms of "The human sexual response cycle" model. Annual Review of
Sex Research, 2, 1-23.
(3) Tiefer, L. (1986) In pursuit of the perfect penis: The
medicalization of male sexuality. American Behavioral Scientist, 29, 579-
599.
(4) Tiefer, L. (2000) Sexology and the pharmaceutical industry: The
threat of co-optation. Journal of Sex Research, 37, 273-283.
(5) Tiefer, L. (2001) The 'consensus' conference on female sexual
dysfunction: Conflicts of interest and hidden agendas" Journal of Sex
& Marital Therapy, 27, 227-236.
(6). Tiefer, L. 38. Tiefer, L. (1996) The medicalization of
sexuality: Conceptual, normative, and professional issues. Annual Review
of Sex Research, 7, 252-282.
(7). Tiefer, L. (2001) A new view of women's sexual problems: Why
new? Why now?. Journal of Sex Research, 38, 89-96.
Competing interests: No competing interests
In their account of the medicalisation of sexual behaviour, Hart
& Wellings do not pay sufficient attention to the HIV-Aids prevention
efforts that were undertaken during the mid eighties and that can be
considered to be the most significant effort to medicalise sexuality in
the XXth century. The enormous amount of social, scientific, medical and
public health responses generated on this occasion are evidence of the
complex and multiple dimensions of such a process.
In the absence of a vaccine and of a "magic bullet" against the virus and
the disease it engenders, public health authorities had to develop a
comprehensive prevention strategy . This included (1) the undertaking of
national surveys on sexual behaviour in most industrial and developing
countries to collect information on the sexual practices of the respective
populations to an extent never before attained in history. (2) A dramatic
change of sexuality-related values and meanings (heterosexual intercourse
becoming a major "risk behaviour"; masturbation considered as a low risk
practice, etc). (3) A global strategy of "behaviour modification" to
promote behaviour change (systematic use of condoms, reducing the number
of partners, etc).
An overall evaluation of the response to AIDS today reveals, on the one
hand an insufficient level of response by public health authorities as
evidenced by the increasing numbers of HIV carriers in developing
countries and among vulnerable groups in industrialised countries. On the
other hand, it represents the most important and comprehensive effort
towards controlling sexual activity, and changing its meaning on the
global level.
The inclusion of the responses towards HIV-Aids would have allowed Hart
and Wellings to give a more balanced analysis of the process of
"medicalisation" of sexuality.
Competing interests: No competing interests
Graham Hart and Kaye Wellings reflect on the extent and consequences
of the medicalisation of sexual behaviour except they did not mention the
HUGE effect that this medicalisation has had on men in America starting
from the late 1890's.
Doctors from this era employed circumcision to deter the practice of
masturbation(1) and circumcision is still done today. Though doctors give
various new reasons for it, the fact remains that it began as a way for
doctors to control sexuality. Now most American men are missing one of the
most sensitive parts of their penis and, one might say, are living in a
fool's paradise.
Regards,
Neil W. Peterson
(1)Angel Money, Treatment of Disease in Children, Philadelphia:
P.Blakston, 1887. p.421
Competing interests: No competing interests
I wish that someone had edited out the irrelevant expression "admirer
of muscular working men" in the description of Edward Carpenter in this
article. Why not just say that he wrote about homosexuality? The sexual
orientation of Stopes and Kinsey wasn't mentioned.
I doubt that "admirer of busty blonde waitresses" would have got
through.
Competing interests: No competing interests
Medicalisation or sociobiology?
I find your description of the medicalisation processes of the human
sexuality as very interesting and elucidating the perverse effects of the
reliance on a technical rationality in the secular or modern western
societies. Hirschman (1981) wrote as follows about this increasing
"genital orientation":
“In a book review about Clifford Geertz recently wrote a marvelous
paragraph that is eminently applicable to the writings to which I have
just been referring:
This is a book about the “primary male–female differences in sexuality
among humans” in which the following things are not discussed: guilt,
wonder, loss, self–regard, death, metaphor, justice, purity,
intentionality, cowardice, hope, judgment, ideology, humor, obligation,
despair, trust, malice, ritual, madness, forgiveness, sublimation, pity,
ecstasy, obsession, discourse, and sentimentality. It could be only one
thing, and it is. Sociobiology.”
Competing interests: No competing interests