October 19th, 2012
This week sees the publication of an (open access) paper by Katherine Angel entitled Contested psychiatric ontology and feminist critique: ‘Female Sexual Dysfunction’ and the Diagnostic and Statistical Manual. While the title’s a bit of a mouthful, the rest of the paper is a great overview of the recent history of medicalisation and female sexual dysfunction. Something Katherine has been researching and challenging for many years.
Within the paper, three key issues caught my attention. The first was Katherine’s suggestion “that existing literature on Female Sexual Dysfunction (FSD) has not yet posed some of the most important and salient questions at stake in writing about women’s sexual problems in this period, and can only do this when the relationship between ‘second-wave’ feminism, ‘post-feminism’, psychiatry and psychoanalysis becomes part of the terrain to be analysed, rather than the medium through which analysis is conducted”. This interests me as looking at how we approach and frame discussions in this area can be as useful to unpack as the wider problems of medicalisation. It also helps us highlight differences in approach – for example it is possible to address the idea of medicalisation and Female Sexual Dysfunction from a feminist perspective, but not everyone who has problems with FSD identifies as feminist. Some may have issues with feminism or even actively oppose it but still be concerned over medicalisation. Or it may be people identify as feminist but still have major problems with the frequently atheoretical and over simplistic sex positive feminist views regarding intimacy. Some of which may be subject to the same problems of commercialisation and aspirational messaging as medicalised discourses. Looking at how different disciplines focus on this area also lets us see how debates are interpreted and reinterpreted through wider discussions in healthcare, medical ethics, economics and so on. (You can hear some of these approaches played out in this Maudsley Debate myself and others took part in on FSD).
One of the big problems in writing about women’s sexual problems is academics frequently rehearse the idea that women’s sex lives are under researched. This in turn is repeated by the mainstream media, partly because they take it at face value and partly because some journalists may have few ideas about where to (aside from a quick google search) to look for evidence on this topic. So the second thing I liked about Katherine’s paper is her noting “Women’s sexual problems have been written about prolifically during the 20th century, in sexological, gynecological, psychiatric and psychoanalytic literature, as well as mar- ital advice material” (she goes on to list many of these studies). This is well worth keeping in mind for the next time you see it claimed that we need more (drug company) funded research on female sexual dysfunction because it is such a taboo and under studied area. Studying the sex lives of Trans and Cis men and women is undoubtedly interesting and there is a lot still to reflect on regarding psychosexual problems and many other topics. But claiming women’s sexuality has not been studied remains both ahistorical and unhelpful. And I would like to see practitioners, journalists and academics stop repeating it.
Within the discussions of FSD and medicalisation more widely (particularly tracing the history of terminologies and psychosexual problems in the DSM), there was a third issue I was drawn to in Katherine’s paper. In the section ‘Multiplicity’ Katherine says:
“Take, for example, the pages of Cosmopolitan. Sex psychotherapist Rachel Morris responds to a letter about libido problems:
‘A lack of desire can be due to many things’, hormone imbalance included, . . . but usually it’s down to a psychological or emotional block. There are so many reasons to freak out about sex – what if I’m no good? What if I don’t orgasm? It could be that you let negative thoughts freeze desire before it starts. . . . Adding pressure will only make it worse, and stress, depression and anxiety are libido killers. Sexuality can’t be forced – it has a life of its own. Talk to your GP and ask for psychosexual counselling. (Cosmopolitan, May 2001: 36)
￼Similarly, Jennifer and Laura Berman, authors of the best-selling For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life (Berman is also the author of The Passion Prescription: Ten Weeks to Your Best Sex – Ever!), and prolific in medical journals also, advocate a significantly medical and pharmacological framework for sexual problems, especially the virtues of Viagra and testosterone; but they too see fantasy, imagination and thoughts as key to ‘helping your- self’ with your sexual problems. In these texts, emotional, behavioural and cognitive habits are on a par with medical drugs, pornography and sex toys; factors key to enhan- cing pleasure and overcoming sexual problems. Likewise, health information websites such as Netdoctor identify a range of factors in sexual problems (Webber and Delvin, 2011), and a representative article in the American Family Physician lists, as possible causes of sexual problems: medicines; diabetes; high blood pressure; alcohol; vaginal infections; menopause; depression, ‘an unhappy relationship or abuse (now or in the past)’; the stresses of everyday life, or being ‘bored by a long-standing sexual routine’ (American Family Physician, 2000: 141–2).
The ontology of sexual problems we see in a range of resources is, I think, more cacophonous and multiple than a focus on pharmacological reductionism suggests. It is per- haps an index of a late 20th- and early 21st-century ‘surveillance’ medicine in which multiple symptoms and signs become risk factors for future outcomes (Armstrong, 1995; Rose, 2007). And yet, while a great many things – hormones and emotional blocks, as Cosmopolitan tells us – are relevant to sexual problems, they are not all equal”.
As someone who has been challenging medicalisation of sexual problems (for women and men) but who also gives advice within the media, this categorisation gave me pause for thought. We know from epidemiological research (some of which I’ve completed with colleagues) there are multiple mental and physical health and social and cultural factors that can either lead to sexual problems, or at least lead to people feeling anxious about their sex lives. Indeed a lot of misinformation from the medicalisation messages that start within pharmaceutical research and end up in mainstream media can convince us that frequent (penetrative) sex that ends in orgasm is vital to the survival of our relationships. And if this does not happen or we do not want it there is something wrong with us. In this case, listing there may be multiple reasons for not feeling like sex, many of which might be completely understandable, can be a way of challenging the more medicalised ideas of ‘normality’. So can listing diverse ways of what might enhance desire and what might be done if trying things to help yourself do not work. Which, in the UK at least, frequently includes at least one mention of ‘talk to your GP’. Which we know isn’t always useful as GPs are busy, aren’t always competent or sympathetic in discussing intimate issues, and potentially still taps into a medicalised view of sex – even if our intention as advice givers is to challenge that. (You can see a good example of me getting caught out in this way just last week).
Up until reading Katherine’s paper I had been seeing medicalisation as something that was originating from the pharmaceutical industry, supported by some quarters of academia and research, and amplified by bad science/aspirational/commercialised sex coverage in the mainstream media. Having read the paper it has left me thinking that even when we attempt to reveal the widespread problems with medicalising sex and offer alternatives, we are still part of wider discussions of sexual issues. And while we may think we are subverting what are now quite mainstream medicalised messages, we may well be adding to what Katherine describes as the ‘cacophony’ of conversations in this area.
All of which I think presents sex researchers, therapists educators and writers with some interesting challenges. Firstly to reflect on their own practice, secondly to situate their writing/research/therapy/teaching within wider conversations about ‘sex problems’, and thirdly to consider how core messages – even ones designed to subvert – may in fact be adding to but not challenging or moving on discussions in this area.
There have been complaints made to the FDA about it being ‘sexist’ for not approving particular drugs for female sexual dysfunction. With backers of the complaint in some cases having close ties to the pharmaceutical industry (although not all complainants in that category). This move has been firmly criticised in this response ‘Female Viagra and the FDA’ which focuses on Flibanserin but relates to other debates in this area.