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Chapter 11

The Scientific and Medical Study of Sex

Introduction

The scientific study of human sexual behavior is a relatively recent phenomenon dating from the late nineteenth century. In the Western world at least, sex has typically been studied through the lens of religion and most often in terms of sinful action and thoughts. Christianity in particular has taken a rather restrictive view of sex and of sexual pleasure. And the Roman Catholic Church continues to believe that the only legitimate sexual activity is (potentially) pro-creational intercourse between a married man and woman. This book has of course been a philosophic exploration of sex, which has often engaged in a dialogue with and/or a critique of traditional sexual views. In this chapter we shall redirect our attention to an exploration of the scientific study of sex and its recent “medicalization,” a term we will explain later in this chapter. In particular, first we will investigate what is meant by a scientific study, considering two quite different views of the subject, one called positivism and the other social constructionism. Second, we will then examine briefly some of the history of sexology to see to what extent we can legitimately call sexology a science. We follow that by a consideration of a recent controversy in sexology and biology regarding female orgasm, and in particular whether it serves a biological, reproductive function. We will be on the lookout here to see whether scientific investigations into this matter have been guilty of the sort of male bias that has traditionally haunted sexology (along with other fields within science). Finally, we shall explore the recent medicalization of sex which has been the subject of considerable debate lately. A number of people believe that such medicalization has resulted in the construction of numerous sexual “dysunctions” that medical experts under the influence of big pharmaceutical companies say need to be treated by drugs. If this is true, then it puts the legitimacy of much recent scientific research into question and raises the same sorts of concerns that people used to have about tobacco company sponsored ‘scientific’ research that concluded that smoking cigarettes was not dangerous to one’s health.

Defining science

One popular view of science is that it tells us what is the case as opposed to what ought to be the case. Hence, for example, while a religious view of sexual activity will tell us what sexual behaviors we are allowed to engage in and those we are not, a scientific view will tell us what activities we do engage in, whether those activities are religiously sanctioned or not. The Oxford English Dictionary points to this descriptive aspect of science when it defines scientific method as: "a method of procedure that has characterized natural science since the 17th century, consisting in systematic observation, measurement, and experiment, and the formulation, testing, and modification of hypotheses" (OED, 2010). There are a number of things to note about this definition. First, science must work with objects that are observable, at least in theory, even if one has to use powerful tools to observe them, or to ‘see’ them only indirectly through their effects. Many have said that this means that science is inherently materialistic, i.e., that it examines physical, material objects, forces and processes. Second, that science does more than observe this matter; scientists measure and perform experiments upon it. How these experiments proceed has been a matter of much philosophic debate. One influential account of the experimental method of science was first developed by a seventeenth century English scholar, William Whewell, which he called the hypothetico-deductive method, and which has been advocated in various forms by many contemporary thinkers. According to this theory, scientists must begin by formulating a hypothesis, which is a suggested answer to the question under investigation. The scientist then proceeds to see what is implied by the hypothesis. That is, what would be true if the hypothesis were true? The implication of the hypothesis is then tested in an experiment. If the experiment is ‘successful,’ the hypothesis is (inductively) confirmed; but if it is not successful, the hypothesis is proved false and must be rejected (See, e.g., Hempel, 1965).

Consider a simple example. Imagine that your car won`t start. You think that it may be out of gas. We can call this your hypothesis regarding the car’s inability to start. If this is indeed the cause of your problem, then putting gas in the car should start it. We can call this the implication of the hypothesis. In this case, it’s a prediction of sorts: if the car had gas, it would start. To test this, you put gas in the car. If the car starts, your hypothesis is confirmed; if it does not, then your hypothesis is falsified and you have to come up with an alternative hypothesis regarding the car`s failure to start. For example, it might have a faulty starter, or the battery is dead.

While actual hypothesis formation and experimental testing can be incredibly complex, the above simple example points to a number of important features of how science proceeds and how it differs from methods of inquiry in other fields, such as philosophy, religion, or English literature. According to the influential philosopher of science, Karl Popper (1959, 1963), scientific enquiries must be what he called “falsifiable.” Clearly, this doesn’t mean they are false. Rather, it means that the hypotheses that scientists put forward must be tested and it must be possible that the hypothesis fails the test. This is the case in our example given above. It was possible that our hypothesis that the car wouldn’t start because it was out of gas is certainly testable, and it’s possible that the hypothesis could fail the test. This view of science is often referred to as Positivism, Scientism, or Scientific Realism. It has been very popular and influential but started to come under attack in the middle of the twentieth century, which we discuss below. It needs to be noted, however, that despite attacks upon it, the Positivist view of science is still held by many people today, especially by people working in the natural sciences, such as chemistry, physics, and biology.

An alternative view of science can be traced back to the work of Thomas Kuhn whose highly influential The Structure of Scientific Revolutions was published in 1962. One of Kuhn’s basic points is that scientific inquiry can occur only within a worldview or conceptual framework, which he called a paradigm. Such paradigms contain, he argued, answers to some basic questions about the area of scientific investigation under study, which scientists working in the discipline agree on. For example, contemporary biology assumes a (roughly speaking) Darwinian framework; that evolution occurs, and does so by the process Darwin called natural selection, and which often gets associated with the phrase, `survival of the fittest.` This is not to say that biologists have no good reasons for believing in Darwinian evolution or that they agree on everything. In fact, they can and do disagree, sometimes quite radically, about any number of things. But they agree on the paradigm, and indeed think that disagreements only make sense within that framework. We will look at an example of such a disagreement in a moment when we look at the disagreement scholars have had about the nature of female orgasm. The point we wish to make at the moment is a bit different. It is that what counts as facts in science are dependent upon scientists agreeing about a great many things about the nature of the universe. Critics of Positivistic science claim, however, that this agreement between scientists is as much a sociological fact as it is an objective claim about the basic truth of the external world. As a result, these critics claim, science has some subjective (or intersubjective) component at its base, as opposed to the positivists who tend to think that science gets at the objective truth of things. This point about subjectivity is especially important to people who come from historically marginalized groups, like women and racial and sexual minorities. Indeed, as we shall see in a moment, that is exactly what some have claimed about studies of female orgasm. It has been studied mostly by male scientists, and as a result has assumed certain things that are far more true of male sexual experience than of women`s.

Approaches such as the one described above have come to be called social constructionist views. The idea behind this position is that we actively interact with the surrounding world – reality, in other words – and through our beliefs about it, actually create or construct it, at least in part. The feminist philosopher of science, Ruth Hubbard (1989), has said that as a result of this, we must always be conscious of who the “fact makers” are. Typically, she argues, in the Western world, they have been wealthy white men, who have been the most dominant and powerful group. As a result we must scrutinize the so-called objective claims of science as being simply the views of a powerful group within society keen on keeping its dominant position.

The so-called ‘science wars’ of the 1990s was a sometimes heated dispute between people who espoused either a positivistic or social constructionist view of science. We don’t propose a solution to this dispute. Our point in raising the issue here is to determine whether sexology is a science on either of these two views. Our answer to this isn’t a straightforward yes or no. Rather, our discussion will reveal that different sexologists have adopted different views of science – some are positivists but others are social constructionists. Moreover, while some that have tried to be positivists have failed in their attempt to do so. This is particularly true of the first and second generation of sexologists.

Is Sexology a Science?

Sexology began in the late nineteenth century. While the first generation of sexologists tried to be what they believed was scientific, they were overly constrained by the morality of their day. Hence, they were particularly interested with examining what they considered to be deviant sexuality, and this including almost everything except pro-creational sex between a married couple. Some argued, moreover, that it was possible even for married pro-creational sex to be deviant or at least problematic. For example, Elizabeth Osgood Goodrich Willard, who coined the term sexology, thought sex for women was inherently dangerous. An orgasm, she said, was more debilitating to the system than a hard day’s work. We must be vigilant, therefore, to stop the waste of energy

through the sexual organs, if we would have health and strength of body. Just as sure as that the excessive abuse of the sexual organs destroy their power and use, producing inflammation, disease, and corruption, just so sure is it that a less amount of abuse in the relative proportion, injures the parental function of the organs, and impairs the health and strength of the whole system. Abnormal action is abuse (Willard, 1867; cited in Bullough, 1994, 26).

Two of the major sexual preoccupations and worries of that time were masturbation and homosexuality, which most researchers believed were deviant and unhealthy. The French physician, Tissot (1728-1787), for example, believed that because semen was vitally important to male health, excessive sex and onanism (his term for all non procreative sex, including masturbation) could lead to everything from unclear thinking and acne to tuberculosis, intestinal disorders, and impotence. He thought the case was even worse in women since, in addition to all the above problems, onanism could lead to lesbianism. And in prepubescent adolescents, the problems were worse once again since they could also lead to insanity (Bullough, 1994, 20-22).

Richard Freiherr von Krafft-Ebing (1840-1902), who published Psychopathia Sexualis in 1886, was perhaps the most significant writer about sexuality in the nineteenth century. A medical doctor and psychiatrist, Krafft-Ebing shared many of the rather conservative beliefs of his time while struggling to think of sex, and of sexual ‘deviancy’ in newer, less judgmental ways. Thus, while he believed, for example, that homosexuality was not necessarily degenerate and perverse and that homosexuals could be ‘normal’ in the non-sexual parts of their lives, he also believed that sexual desire was always potentially dangerous and hence had to be tightly controlled. Uncontrolled sexual desire, he felt, was like a “volcano which scorches and eats up everything, or an abyss wherein everything is walled up – honor, property, health. [By establishing monogamous marriage and reinforcing religious bonds] Christian peoples obtained a spiritual and material pre-eminence over other peoples, particularly those of Islam” (cited in Bullough, 48). Clearly, Krafft-Ebbing has here crossed entirely over the line of describing sexual behavior and entered the realm of moral pontification. Claims such as this are surely not scientific in any recognizable sense of that term.

The most significant figure in the second generation of sexologists was Sigmund Freud (1856 – 1939), the Austrian neurologist and father of psychoanalysis. His theories were the most influential within psychiatry for at least half a century, and he continues to be influential in fields as disparate as literature and sociology. Freud believed that sex was at the root of almost all human behavior and believed in particular that the vast majority of our psychological problems stemmed from some sexual cause. In fact he claimed at some points in his career that all neuroses had a sexual cause.

Freud’s overarching theory is complex and the subject of intense debate and so we won’t be exploring it any detail here. Instead, we will provide a brief overview of his theory and indicate on what basis he came to think as he did in order to see whether his views were scientifically based.

The historian of sexology, Vern Bullough (1994, 88), provides a nice summary of Freud’s overarching thoughts in the following passage:

[At the end of] his own self analysis … (about 1902), Freud emerged with the conviction that he had discovered three great truths: that dreams are the disguised fulfillment of unconscious, mainly of infantile wishes; that all human beings have a Oedipus complex in which they wish to kill the parent of the same sex and possess the parent of the opposite sex; and that children have sexual feelings. He later added two ideas to these emerging principles of psychoanalytic thought, namely the division of the human mind into superego, ego, and id, and the concept of the death instinct (thanatos).”

The first sentence of this passage gives us a clue as to the basis of Freud’s beliefs, namely “analysis,” in this case, self analysis, which is a form of introspection or a “case study” of oneself. Indeed, case studies really form the basis of Freud’s beliefs, though this is true only in a complicated way, as we shall see. Indeed, many of the early sexologists relied heavily on case studies when formulating and/or defending their views about sex. While case studies have a veneer of scientific acceptability behind them since they are based, theoretically, on empirical evidence, this can be far from the actual truth. Properly done, a case study can tell us a great deal about a particular person (see, e.g., Levin, 2007 and Elliott, 1998), but they become problematic when (1) they are used to generate claims about large groups of people or even of all people, and/or (2) they are not properly done. Freud, along with the rest of the first and second generation sexologists, suffered from both of these problems.

Regarding problem (1), consider as an example the highly influential early English sexologist, Havelock Ellis (1859 – 1939). His theories were drawn largely from case studies of himself, his wife, and their friends. Unfortunately, from a research perspective, they were distinctly un-representative of the populous at large. Ellis’s wife was a lesbian and Ellis suffered through long periods of impotence, and had a fascination with urolagnia. And their friends, especially Mrs. Ellis’ friends, tended to be part of the gay and lesbian community and certainly were not part of mainstream sexuality in Victorian England. This isn’t to attack Ellis, his wife, their friends, or their sexual orientations or proclivities; rather, it is to say that the data acquired through case studies of these people may not be generalizable to the population as a whole. Freud made a similar mistake by drawing almost all of his ‘empirical’ data from his patients who suffered from some neurosis or other. It was for reasons such as this that Beatrice Faust (1980) claimed that “it is always possible to discover a few case histories to support any particular argument but case histories only illustrate they don’t verify.” And even Freud himself said of this method that, “It strikes me as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science” (Freud, 1895).

For reasons such as this, contemporary medicine has largely rejected case studies and claims that rely mostly or exclusively on the physicians’ ‘clinical experience’, and turned to what is called “evidence based medicine,” which relies on more scientifically legitimate evidence, theoretically at least.

Regarding problems of type (2), Freud is once again a prime example. As we discussed with respect to the view of science first taken up by Kuhn and developed later by the social constructionists, science, like all other fields of inquiry, does not exist in a vacuum. Researchers bring to their investigations a particular view of the world, or paradigm, and these paradigms can be deeply biased. So, while Freud was told by a great number of his female patients that they had been victims of sexual abuse, typically by close family members, he simply refused to accept their testimony, opting instead to believe that these women were delusional. As we shall discuss in greater detail in the next section, Freud also refused to believe women with respect to the origin of their orgasms. Because of his overarching theory about “psychosocial development,” which we discuss further below, Freud believed that all fully mature and non-neurotic women will change from an earlier stage of clitoral orgasm to a stage typified by vaginal orgasm -- despite what his patients actually told him.

Problems like this are behind the claims by Karl Popper, who we mentioned above, that Freudian psychoanalytic theory is unscientific because it refuses to put forward hypotheses that it is willing to have falsified. That is, Popper claimed it should be the case that hypotheses – like the source of orgasms in women – can be falsified by empirical evidence. Instead, Freud – in this and many other instances that we haven’t discussed here –repeatedly claimed there was something wrong with the empirical data, or that it was being incorrectly interpreted and applied, and continued to hold firm to the truth of his theories and hypotheses.

The third wave of sexologists attempted to avoid the problems of the previous generation by eschewing case studies in favor of large samples of people, which they claimed were representative of people in general. The two most important streams to this new approach were Alfred Kinsey (1894-1956) on the one hand and William Masters (1915-2001) and Virginia Johnson (1925-) on the other.

Trained as a biologist, Kinsey was adamant that human sexuality could be studied scientifically. To this end, he set out to collect data through long intricate interviews, which he himself designed, and taught to only three other individuals who came to work at his Institute at Indiana University.[1] These four men interviewed approximately 18,000 individuals, and the data they collected formed the basis of Kinsey’s two major works or reports: Sexual Behavior in the Human Male (1948) and Sexual Behavior in the Human Female (1953). These reports turned out to be incredibly popular with both of them making bestseller lists. Given the subject matter, they were also highly controversial. In terms of content, the book on male sexuality received lots of disapproval because of its claim that a much higher percentage of American males had engaged in at least one homosexual experience (37%, according to Kinsey, 1948), and that bisexuals were not, contra Freudian theory, homosexuals trying to adapt in a homophobic society. The book on female sexuality raised doubts about the widely accepted belief at that time that almost all women remained virgins until they got married. According to Kinsey (1953), 50% of American women had intercourse before marriage. Also shocking to people at the time was Kinsey’s claim that about 26% of American women – and 50% of American men – had engaged in extramarital or adulterous sex (Kinsey, 1948, 1953). It is in fact fair to say that Kinsey’s work substantially changed the sexual landscape in America by demonstrating that Americans were not nearly as conservative and constrained in their sexual behavior as public perception at that time would lead one to believe.

Kinsey’s work was clearly far more scientifically based and rigorous than the work of most of his predecessors. Even so, however, his methodology was attacked with critics saying that his samples were not random and hence not generalizable. For though Kinsey did not rely on single or small scale case studies as many of the earlier sexologists had, his samples were not as random and representative as they should have been. First, Kinsey relied on volunteers and this led to a worry because people who volunteered to be interviewed about their sexual life might be more liberal than the general populace. Second, his subjects were mostly from the mid-west region of the United States not too far away from Indiana where he was based. Finally, the male study in particular contained a disproportionate amount both of prisoners and homosexuals. All of these problems raised concerns about the representativeness of his samples (Bullough, 176-177).

William Masters was an obstetrician with a clinical background that Kinsey didn’t have. For this reason, he and his eventual research partner and wife, Virginia Johnson, were at least as interested in helping patients as they were with accumulating data. Besides advancing knowledge about human sexuality, then, they also made important innovations in the treatment of sexual dysfunction, in part by constructing a new field/position in sex therapy -- the sex therapist. Sex therapy, as conceived by Masters and Johnson, was an alternative to Freudian psychoanalysis, which dominated the treatment of sexual dysfunction at that time. Most sex problems were not, they argued, the result of any deep psychological neuroses that had to be dealt with by long periods – typically years – of psychoanalysis. Rather, they maintained, most sexual problems were relatively easy to resolve and were the result of a lack of knowledge, whether with respect to anatomy or the preferences of one’s sexual partner (see Bullough, 203-205). Of particular interest, both in terms of their research and their therapeutic mandate, Masters and Johnson constructed a four stage sexual response cycle beginning with the excitement phase before entering the plateau phase, the orgasm phase and ending in the resolution phase (Masters and Johnson, 1966). This model is still widely used today. They were also aware that men and women can differ in their sexual responses. For example, women can more easily return to the plateau phase and experience multiple orgasms than men can. Indeed, as we detail below, the years after Masters and Johnson saw a remarkable rise in the number and variety of studies about gender. In a way, the studies of Kinsey and Masters and Johnson, which relied heavily on large samples and statistical analysis, gave rise to studies of gender that took a completely different tack on investigating their subject matter.

The term ‘gender’ itself, as something distinct from the biological category, ‘sex’, was first coined by John Money (1955), a psychologist who spent most of his career at Johns Hopkins University in Baltimore, Maryland. Sex is a biological category that refers primarily to genitals whereas gender refers to the ways in which we as a culture – at a particular time and place – perceive the categories masculine and feminine. Hence, that only a woman can carry a fetus inside her and give birth is, so the distinction goes, a biological fact of sex: that women must be the primary caregivers for babies, infants, and children is a cultural construct about gender based on our ideas about the roles of mothers and fathers. This distinction, though challenged over the years, still has fairly broad acceptance in some form or other: it was also fundamentally important during the 1960s and 1970s for the second wave of feminism. It allowed such feminists to argue, persuasively, that biology is not destiny and that women do not necessarily have to be, by the very nature of their genes, wives and mothers. This opened up a whole new area of research, spearheaded by Money amongst others, regarding “gender identity.”

Gender has, of course, been studied in a variety of different disciplines, and hence in a variety of different ways. Some of these fields of investigation – in literature departments, for example – are not scientific investigations, nor do they claim to be. However, it’s important to note that part of the feminist enterprise was to reevaluate disciplines including their methodologies and their self perception. Along with others, feminists have over the past 50 years been incredibly influential in re-conceiving science. In particular, they have been influential in developing a social constructionist view of science that stresses how so called objective studies are in fact the deeply biased views of researchers, almost always white males from the privileged class, defending their privileged position in society.

In this vein, the work of Michele Foucault has been particularly important in the history of sexology. A major tenet of Foucault’s thought is that knowledge and power have become increasingly connected in the modern western world – so much so that Foucault often referred to them in a hyphenated fashion, “knowledge-power,” (Foucault, 1975/1977) to signify their interdependence. He used this idea to deconstruct the claim of modern science that what it has ‘discovered’ is objective fact and hence is not subject to change. In contrast, Foucault argued that what we often take to be necessary is in fact contingent. That is, that what we think can’t be changed can in fact be changed (Foucault, 1961/ 1976 and 1963/1965). Consider in this respect various claims that have been made by modern approaches to sexuality, including Freudian psychoanalysis, about the nature of sexuality. For example, it has been claimed that women are ‘naturally’ given to hysteria, and that atypical sexual proclivities or orientations, like homosexuality, are forms of mental illness that must be treated through medical interventions, mostly through psychiatrists and psychologists (Foucault, 1976/1988). Foucault rejected such claims arguing that the categories ‘hysterical woman’ and ‘mentally ill homosexual’ were cultural constructs created by mainstream heterosexual men.

We can see, even from this brief examination of the history of sexology that people working within the field have taken widely different tacks in their investigations. Some failed to be scientific in any recognizable conception of the term, while others clearly were scientists employing what are widely accepted as scientific procedures. Still others have been part of a re-conceptualization of science and hence of sexology --- so much so that what they are doing has been held to be actively anti-scientific by those holding a different view of what science is.

In fact, as Vern Bullough argues at the end of his history of sexology (1994), current scientific studies of sexuality (including those discussed above that provide a critical assessment of such studies, traditionally conceived) do not fit into one coherent pattern. People currently studying sexuality come from a wide array of fields – from biology, neurology, medicine, psychology, sociology, anthropology, to literature, philosophy, and women and gender studies – and bring with them a wide variety methodological approaches. Hence, there is no single and simple answer to the question whether current sexology is or is not a science. At the end of this chapter we will, however, consider some material on the extent to which current scientific studies of sex may have become unduly influenced of Big Pharma hence raising concerns about their scientific validity. Before exploring that issue, however, we examine another controversy that speaks to the objectivity of contemporary scientific studies about sex.

Female Orgasm

In this section, we examine two issues: (1) the source of female orgasm – the clitoris or the vagina; and (2) whether orgasms in women fulfill any biological, reproductive function. We should make absolutely clear what we mean by this second issue. Clearly, female orgasms have many functions. Most obviously, orgasms in both men and women can be and typically are tremendously enjoyable and hence at least a part of human happiness. People often find deep meaning and significance in sex in general and orgasms in particular. Nothing that we say here puts any of these claims in dispute. Rather, the issue we examine here is restricted to whether orgasm in women adds to our evolutionary fitness; i.e., do orgasms in women increase the likelihood of our survival as a species.

As we mentioned earlier in this chapter, Freud was highly influential on the matter of female orgasm. According to Freud, humans have an instinctual sexual drive that, ideally, passes through five stages of what he called “psychosexual development:” (i) the oral, (ii) the anal, (iii) the phallic, (iv) the latent, and (v) the genital. These stages indicate the erogenous zones that are the source of our libido or sexual desire during specific ages. Freud maintained that the last stage of this process represented full adult maturity where sexual desire was focused on heterosexual penis-vagina intercourse and reproduction. Failure to reach this end stage, he said, was often an indication of a neuroses or mental illness.

The phallic and genital stages are the ones important for our discussion here. In the phallic stage, which occurs from the ages of 3-6, sexual desire is focused on the genitals as boys and girls explore their own and others genitals, and first become aware of the difference between them. This leads to a castration complex in boys – the fear that boys will be castrated either literally or metaphorically by being degraded, humiliated, or emasculated. Freud argued that this is all part of what he called the Oedipus complex, which is the sexual desire by boys for their mothers and a concomitant desire to kill their fathers (as competitors for their mother’s love). Girls suffer instead from “penis envy,” which she relates to power and her wish to possess such power. These desires are part of the “Electra Complex,” which is girls’ sexual desire for their fathers and the accompanying wish to kill their mothers. Briefly, resolving these complexes involves coming to identify with your same sex parent and transferring your sexual desire to members of the opposite sex other than your opposite sex parent. In terms of sexual activity, movement from the phallic to the genital stage is marked by an end of self exploration and masturbation, to the exploration of others and to intercourse.

According to Freud, adult (i.e., post-puberty) women who focused on their clitoris are stuck in the immature, childish, phallic stage of development. In his New Introductory Lectures in Psychoanalysis, Freud wrote that post-pubescent women are supposed to embrace their proper role as a passive, female being, i.e., someone who accepts the male into her. “With the change to femininity, the clitoris should wholly or in part hand over its sensitivity and at the same time its importance, to the vagina” (Freud, 1953-74, 22.118).

Freudians themselves, particularly feminist ones such as Karen Horney, hotly debated Freud’s claims here, but despite such internal debates, Freudian psychology has created an impression of women’s sexuality as passive and centered on the vagina. Unfortunately, this has created untold harm for women who can’t (or typically don’t) orgasm through vaginal stimulation alone, which represents the vast majority of women. A case in point is Princess Marie Bonaparte, whose great-grand uncle as Napoleon Bonaparte. Though she had an active sex drive, and could attain orgasm through masturbation involving direct stimulation of her clitoris, she could not attain orgasms by vaginal penetration alone. She came to believe that the problem was with her; specifically, that there was too great a distance between her clitoris and her vaginal opening, which in her case was almost 3 centimeters. Intrigued, Princess Marie began collecting data (eventually published in a medical journal in 1924) which led her to conclude that women with a space of 2.5 centimeters (about an inch) between their vaginas and their clitorises almost never reach an orgasm through intercourse alone. Women below this 2.5 centimeter range most often can attain orgasm through intercourse alone, while women at the border line can only occasionally attain orgasm in this manner. This data has in fact recently been confirmed (Roach, 2008, 65-71). As interesting as this data is, the truly remarkable thing about this story is that Bonaparte had her clitoris removed and reattached closer to her vagina. Of course, it did absolutely no good regarding her (in)ability to attain orgasm through intercourse. Part of the reason for this is that the clitoris is not simply the small visible tip at its end. The clitoris is actually approximately ten centimeters (four inches) long and extends along the vaginal wall. (This, in turn is one reason why there continues to be controversy whether so-called vaginal orgasms are really clitoral orgasms since the penetrating object, such as a penis, might actually be stimulating the clitoris through the vaginal wall.) And the whole of the clitoris is made of an incredible amount of nerve endings that are incredibly sensitive. But once her clitoral tip was removed, it was separated from these nerves thus making her clitoral tip rather numb.

How much easier it would have been for her, not to mention far more successful, simply to incorporate direct clitoral stimulation during intercourse. Not doing so demonstrates, unfortunately, how persuasive the idea has become that women are supposed to be able to reach orgasm through intercourse alone. The blame for this idea is male bias in general and the theories of Freud in particular.

Kinsey was – here as elsewhere --one of the first to investigate the matter of female orgasm empirically. This in itself represents a notable distinction from Freud’s claims which are based entirely upon his theory and not upon empirical evidence. According to Kinsey (1953), 39 to 47 percent of women reported that they always, or almost always, had orgasm during intercourse. But, according to Elisabeth Lloyd (2005), whom we will discuss at some length below, this figure is misleading because Kinsey included women who reached orgasms assisted by clitoral stimulation as well as vaginal penetration. Lloyd maintains that although research in this matter is still ongoing, only about 20% of women can reach orgasm without direct clitoral stimulation (Lloyd, 2005).

The rate at which women attain orgasm through intercourse alone will, as we shall see, be an integral part of the issue regarding whether female orgasm serve any biological function? That is, does this particular trait – female orgasm – lead to reproductive success? To help think about this matter more clearly, let’s consider examples a couple of traits that do have reproductive value, such as the white coats and webbed feet of polar bears. Their white coats provide excellent camouflage allowing them to sneak up unnoticed by their prey while their webbed feet allow them to swim from one ice flow to another. Hence, having these traits makes it more likely that individuals who possess them are more likely to survive, mate, and pass on their traits to the next generation. Lloyd expands on this: “On such accounts the traits themselves are called ‘adaptations’, and the explanatory game is to provide a description of the past history of the environment and the organism that reveals how the possession of the trait has contributed to reproductive success of an orgasm that has this trait – or to its relatives’ reproductive success” (Lloyd, 2005, 3). With the polar bear, this would include an account of the white, snow covered land separated by icy, cold water, and to detail the change from darker coloured bears without webbed feet, like the grizzly bears to the south from which polar bears evolved.

With this in mind, consider again our original question whether the trait of female orgasm is an adaptive one? Most evolutionary biologists have said that it is. But after reviewing all 21 published adaptionist accounts of this trait, Lloyd concludes that they are wrong for one reason or another. Following the biologist, Donald Symonds (1979), she claims instead that female orgasm is a “by-product” of evolution, like nipples on men. Obviously, these claims need further explanation and defence. Let’s begin with her preferred by-product account, which is not adaptionist.

In the earliest stages of human fetal growth, males and females have the same physical characteristics except, of course, for different chromosomes. So, male and female fetuses have the same genital beginnings and begin to differentiate only at around 8 weeks of gestation when the male fetus releases hormones that start the process of sexual differentiation. If no hormones are released, then the fetus will continue to develop into a female. Hence, the clitoris and the penis “are the same organ in men and women; there is an organ in the primordial, undifferentiated embryo that turns into a penis if it receives a dose of a particular hormone; otherwise it matures into a clitoris. In other words, the penis and the clitoris have the same embryological origins and thus are called ‘homologous’ organs. Similarly, the nervous and erectile tissues involved in orgasm in both sexes arose from a common embryological source” (Lloyd, 2005, 108).

Despite this background developmental commonality, however, orgasm in men and women have, on the face of it at least, quite different reproductive functions. The male orgasm functions as a delivery system for sperm to be deposited in the vaginal canal of the female to fertilize an egg. The female orgasm does not appear to have a similar ‘delivery’ function. Thus, though the clitoris and penis are homologous, and each serves to produce orgasms (and such orgasms can be pleasant and meaningful for both men and women), their biological function is quite different. In the same way, though the nipples in both men and women can be erogenous zones, male nipples have no biological function since, unlike female nipples, male nipples cannot deliver of milk and feed babies. Both male nipples and female orgasms are, then, in this biological sense, merely a by product of the fact that all human babies share a common early developmental history (apart from their DNA of course).

The adaptionist accounts of female orgasm vary considerably but fall into three broad camps: (1) pair bonding, (2) non-pair bonding, and (3) “sperm selection” accounts. Very briefly, pair bonding accounts maintain that female orgasm helps form and keep a bond between male and female that keeps them together. Many reasons have been offered for why the creation of a pair bond would be evolutionarily selected for and beneficial to both males and females. Clearly, human children are incredibly helpless and require an incredible amount of care over an extended period of time. This makes it very difficult, especially in the hunter gatherer societies from which we all at some point came, for a woman to raise a child (or children) on her own. It would clearly be beneficial, then, for their male mate to remain with her and help and help raise the children. Pair bonding adaptionist accounts suggest that her orgasms help to solidify the bond between her and her mate. In particular, and from the male’s point of view, because males have never been able to tell, until recent DNA paternity testing, whether offspring are theirs, a secure, monogamous coupling provides assurance to the male that his mate will be faithful. Her pleasure with their sexual life, in the form of orgasms, displays her satisfaction with him and hence her unlikelihood of stepping outside the bonded pair for sexual satisfaction. (Lloyd, 2005, 44-76).

The primary problem with all these accounts, Lloyd argues, is that they assume that women are like men and always or usually attain orgasm during intercourse. But this is simply not the case. As we said earlier, only about 20% of women attain orgasm through intercourse alone. Indeed, Lloyd surveys 32 studies conducted between 1929 and 1994 on the frequency of female orgasm during intercourse (see table in Lloyd, 2005, 28-34). “The mean value [of women who said they “always” had orgasm with intercourse] was 25.3% while the median value was 23.5% “ (Lloyd, 2005, 27) She says the two most reliable studies (Stanley, 1995; Laumann et al., 1994), which relied upon “probabilistic sampling techniques” showed that women “always” had an orgasm with intercourse as 18% and 28.6 respectively” (Lloyd, 2005, 27).

Compare these results with the ones reported by women about orgasms attained through masturbation, which is almost always done by direct clitoral stimulation and not by vaginal penetration alone. Here the vast majority of women achieve orgasm and do so much more quickly than they do during intercourse. Indeed, men and women take approximately the same length of time to reach orgasm through masturbation. Lloyd concludes: “The chief empirical problem with [pair bonding adaptionist accounts of female orgasm] is the presence of the substantial gap between the occurrence of intercourse and the occurrence of female orgasm” (Lloyd, 2005, 75.) The odd fact that most researchers have failed to see this, Lloyd contends, is that these researchers have typically been men and have therefore looked at the matter from a male’s point of view. Men almost invariably achieve orgasm during intercourse (unless there is a problem, which we discuss in the next section) and hence there has been an assumption either that women do as well, or if they don’t, that there is something wrong with them. That is, male bias has greatly skewed the investigations.

Non-pair bonding accounts of female orgasm typically begin by noting what pair bond accounts miss; namely that most females do not experience orgasm through intercourse alone most of the time. Researchers within this framework then attempt to use this discrepancy between female orgasm and intercourse as evidence of an adaptation that has evolutionary fitness. Time and space permits us to mention only a couple of these, and readers are encourage to examine Chapter 4 of Lloyd’s book (2005, 77-106) to get her full account.

Sarah Blaffer Hrdy (1981, 1988, &1996) maintains that female sexual pleasure is adaptive. Women, she claims, will seek to continue copulation until she is satisfied. But since women typically take more time to reach orgasm through intercourse then men do, women will have to be promiscuous and mate with several males in quick succession. This is a non-pair bonding account because it entails that women will be promiscuous and not mate with just one male and form a long standing (and perhaps monogamous) bond with him alone. Indeed, Hrdy’s account seems diametrically opposed to the earlier account where it was claimed that women and men will tend towards monogamy so that women will have a mate to help raise helpless children, and men will be assured of their paternity. Hrdy argues, however, that her promiscuity account achieves the same end since in this case, the woman will have a number of men, rather than just one, to help rear her children because none of them know whether the child is theirs. But given the chance that each male is potentially the father of the child, all are willing to help out.

An obvious response to this thesis is that women typically do not engage in sexual practices of this sort. Hrdy acknowledges this and hence claims that this sort of promiscuity is not currently adaptive for humans: it is, rather, a vestige of a behaviour that was once adaptive but no longer is (like a tail bone in people). This claim is, unfortunately, hard to corroborate one way or the other. Even more problematic for Hrdy’s account, however, is that there is no evidence to suggest that the length of intromission (the time the penis is inside the vagina) makes a significant difference regarding female orgasm for the majority of women (Lloyd, 2005, 98).

There are several versions of the “sperm selection” account, but by far the most widely held is the “upsuck hypothesis.” The idea is quite simple: female orgasm causes the uterus to “upsuck” sperm through the vaginal canal thus increasing the chances of fertilization. “If the sperm-upsuck theory is correct, then it would constitute the much sought after connection between female orgasm and a feature, fertility, which might be connected to reproductive success, which would thus make it more plausible that female orgasm serve an adaptive function” (Lloyd, 2005, 180.) But studies performed by Masters and Johnson (1966, 123) offer no evidence for an upsuck of sperm in women while experiencing an orgasm. In fact, quite the opposite is more likely the case: “the contractions of orgasm start at the back or the top of the uterus and go down through the middle, ending in the cervix. In other words, these contractions might have the effect of expulsion rather than ingestion. Masters and Johnson also note that the sperm-suction theory wouldn’t seem to work because the upper end of the vagina around the cervix expands during orgasm, and lifts the cervix away from the pool where the semen would be deposited” Lloyd, 2005, 182).

Lloyd concludes, then, that adaptionist accounts of female orgasm have not adequately made their case. That many researchers have thought otherwise, she claims, is largely the product of male bias and patriarchal thinking.

Medicalization of sex

One rather neutral definition of medicalization is the following offered by Wikipedia: it “is the process by which human conditions and problems come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals to study, diagnose, prevent or treat.” Psychologist and activist, Leonore Tiefer (2003, 35), extends this definition applying it to the medicalization of sex in particular. Note that her description is far more hostile to the concept than the rather neutral one provided above. She claims that medicalization is “a process of establishing universal norms, and then declaring all variations disordered and in need of treatment ….[typically tracking the following pattern:] expensive meetings, books and journals underwritten by drug companies, new disorders discovered to be treated by expensive drugs, health and medical journalists alerting the public to their quick-fix cures, drug-company sponsored epidemiological studies creating and identifying new markets, urgent government and commercially funded consensus conferences. Meanwhile, the factors that account for the lion’s share of women’s [and, we would argue, men’s] sexual problems (economic, social, political) will be ignored, avoided, and generally said to be ‘not about sexuality’. In other words, medicalization is fundamentally about normal versus abnormal function, and fundamentally about defining that in terms of physical performance” (Tiefer, 2003, 35).

Many argue that such medicalization currently has a huge influence on how we think of sexual matters and are particularly worried about the increasing influence of ‘Big Pharma’ in defining what the norm is. Indeed, as we shall see, Pfizer, who makes Viagra, had some part to play in what has come to be called “Erectile Dysfunction” (ED). We will use this event and the subsequent search for a ‘female Viagra’ as case studies about the medicalization process with respect to sex. While allowing that Viagra in particular has some beneficial effects for some men, and couples, we also suggest a number of troubling aspects of this process. At present, it is unclear whether a female Viagra has much of anything positive to offer women.

The word "impotence" has a long history and literally means powerlessness, which has many negative connotations. Hence, when sildenafil, which was marketed eventually as Viagra, was being tested, a change in vocabulary occurred around 1992 to “erectile dysfunction” because it was thought to be “more clinical, more physical, making no judgement about the man’s potency [and] … implied the problem was that a man’s penis wasn’t functioning properly. His feelings and relationships were in a sense left out of the picture” (Moynihan and Mintzes,2010, 123). The most recent version of the Diagnostic and Statistical Manual (DSM), which is published by the American Psychiatric Association and is widely used by psychiatrists and psychologists to classify, list and explain various mental illnesses, currently describes ED as “a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection,” and which causes the person “marked stress or interpersonal difficulty” (APA, DSM IV-TR). Under normal circumstances, “when a man is sexually stimulated, his brain sends a message down the spinal cord and into the nerves of the penis. The nerve endings in the penis release chemical messengers, called neurotransmitters, that signal the arteries that supply blood to the corpora cavernosa (the two spongy rods of tissue that span the length of the penis) to relax and fill with blood. As they expand, the corpora cavernosa close off other veins that would normally drain blood from the penis. As the penis becomes engorged with blood, it enlarges and stiffens, causing an erection. Problems with blood vessels, nerves, or tissues of the penis can interfere with an erection” (Medical Dictionary, 2011)

Sildenafil, or Viagra, was initially tested in the late 1980s and early 1990s as a potential anti-angina drug. Angina is severe chest pain caused by a lack of blood flow and oxygen to the heart and is generally caused by an obstruction in the coronary arteries. But sildenafil failed these tests. However, when doing thm, researchers noted that among a whole host of side effects of the drug -- flushing, headaches, indigestion, muscle aches, and distortion of color vision, -- they also noticed a further one: it produced penile erections. So, beginning in 1993, Pfizer began to test sildenafil as a treatment for ED. Over the next four years, sildenafil underwent 21 clinical trials exposing approximately 4500 test subjects to the drug. The results, according to these trials, appeared very good with an overall ‘success rate’ of around 70% for men with ED, and the drug was approved in the US in March, 1998 and in Europe later that year. 1,000,000 men in the US were given prescription for Viagra in its first few weeks on the market, and by 2006, it was estimated that 750,000 physicians had prescribed various what are called PDE5 inhibitors -- sildenafil (Viagra), vardenafil (Levetra), and tadalafil (Cialis) -- to more than 23,000,000 men in the U.S. (Ghofrani et al., 2006 -- all figures this paragraph). By 2008 US sales had reached $1.5 billion representing 19,000,000 prescriptions. Part of these tremendous sales was due to the fact that more and more ‘elderly’ people started having sex again. 57% of 70 year old men and 52% of 70 year old women were having sex versus 40% and 35%, respectively, 30 years ago. And when the baby boomers, with their disproportionate numbers, begin to enter this age range, the numbers will surge ever higher (Kotz, 2008).

All of the PDE5 inhibitors such as sildenafil are what are called vasodilators, which are drugs that have the effect of dilating the blood vessels. They work by improving blood circulation to the penis, and by enhancing the effects of nitric oxide, the agent that relaxes the smooth muscle of the penis and regulates blood vessels during sexual stimulation, allowing the penis to become engorged and achieve an erection (Medical Dictionary, 2011). Note, however, that none of these medications actively create sexual desire: rather, for approximately 70-75% of men who are sexually excited, they allow for blood flow in the penis necessary for a sustained erection. If, then, a man’s problem is caused by psychological problems, such as sexual performance anxiety, depression, stress, or guilt, rather than physiological ones, then Viagra and its variants will not be effective. Indeed, one need not even be afflicted with a psychological problem. If, for example, one simply has no sexual interest in one’s partner because one no longer loves (or even likes them), then no amount of Viagra will produce an erection. That is to say, relationship issues will not be solved by taking these medications, and studies indicate that about the same percentage of men are affected by such loss of desire as are affected by ED. Interestingly, by far the biggest sexual problem men said they experienced was premature ejaculation (at 21%) and Viagra and other PDE5 inhibitors will do nothing for that either (Leland et al., 2000).

Having said this, however, many men have been happy to have these new drugs on the market. This is perhaps most obvious simply from the amount of people who have taken them – current estimates are 150 million worldwide with the expectation this will rise to 300 million men by 2025 (Padma-Nathan, 2006), even though the cost (or the full cost) of the pills is not covered by most drug plans (and the pills currently cost between $10-20/pill). Besides ‘creating’ and sustaining erections, men taking PDE5 inhibitors tend to experience increases in self esteem and decreases in guilt and depression; furthermore, the majority of men taking these drugs were satisfied with them (Padma-Nathan, 2006). Some studies indicate as well that partners of men taking PDE5 inhibitors are generally satisfied or very satisfied with their partner’s treatment (Padma-Nathan, 2006). Moreover, the current treatment of ED is remarkably better than previous physiological treatments for impotence. Consider, for example, testicular grafts and implants first employed by the Turkish obstetrician, Skevos Zervos, in 1909. This treatment was introduced to the United States a few years later where a third testis was added to the scrotum. Of course, finding donors willing to forgo one of their testicles was difficult and so treatments were developed to use the testes of cadavers. Other researchers tried xenotransplantation, using the testes of everything from sheep to chimpanzees. Unfortunately, none of these worked, for more or less obvious reasons including rejection by the body of these foreign substances. Nor does drinking concoctions made of various types of animal gonads or penis, as is popular in some cultures (Roach, 2008, 177-192). By comparison, then, Viagra and other similar medications are a tremendous improvement.

And yet, there is certainly more to this picture than the above comments suggest. Part of this becomes clear when we look at the advertising campaigns that were launched by Pfizer and others. First, it should be noted that direct marketing happens only in a few countries (but includes the U.S.A. and, to a lesser extent, Canada) and is a recent phenomenon, dating back only to 1996. Clearly such marketing has had an incredible effect the sale of pharmaceuticals almost tripling them over a ten year period from $11.4 billion in 1996 to $29.9 billion in 2005 (Donohue et al., 2007). When Viagra was first marketed, it was targeted to older men and couples. Bob Dole, a former US Senator and Presidential candidate, was one of the first to appear in a commercial for Viagra. Significantly, however, Dole was at that time in his seventies and was recovering from prostate surgery, which is often linked to difficulties getting and sustaining erections. Quickly thereafter, however, Viagra increasingly was marketed to younger and younger men who had experienced no medical difficulties and really no erection problems either. Consider the following magazine advertisement of a “ruggedly handsome man around the age of 40 with the bold headline: ‘Viagra. It works for older guys. Younger guys. Even skeptical guys.’ The ad then asks its readers: ‘Think you’re too young for Viagra? Do you figure, ‘It only happens once in a while so I’ll live with it’? Then nothing’s going to change, especially your sex life’ The message was clear: even the most occasional erection problems could benefit from being treated with a drug” (Moynihan & Mintzes, 2010, 125). Once we begin to categorize every single instance of failure to achieve erection – or even a failure to achieve multiple erections over a short period of time – it is easy to see how surveys can claim that more than half of men over forty experience ED (Feldman, et al., 1994).

Increasingly, the norm of erectile function came to be defined by reference to a healthy twenty-year-old man, and discrepancies from this norm came to be labeled as dysfunctions in need of treatment (See Moynihan & Mintzes, 2010, 122-130). This plays into stereotypes of what constitutes a ‘real man.’ In one poll sponsored by Pfizer, for example, two of the top ten characteristics of “manliness” were “potency” and “always ready for sex” (Asberg & Johnson, 2009). Thus, many men are extremely sensitive to any self doubts about their own masculinity and make easy targets for sales pitches of the sort employed by Pfizer and others. In this context, then, it is not that odd to see so many men taking Viagra and reporting satisfaction with it since such usage protects them from a psychologically stigmatizing self perception. Physicians often add to this problem. Consider the following from a New York urologist, who is also a speaker for Pfizer, who thinks that almost all men over fifty could be helped by taking Viagra: “People think that they have to have severe ED to take Viagra. But that’s not true. It works well for men who can get erections, but the erections aren’t as rigid as they once were. Or they don’t last as long as they used to. Or there may be longer intervals between erections. Now, I prescribe Viagra for men of all ages. But I think just about every sexually active man over 50 could benefit from Viagra” (Moynihan & Mintzes, 2010, 126). An executive at Bayer, which markets Levetra, maintains that “it’s going to be important to communicate to men that it’s okay [to take a drug for this since erectile dysfunction is] just a natural consequence of aging. Kind of like when you reach the age of forty and you start to need eyeglasses” (Moynihan & Mintzes, 2010, 126).

A number of researchers have also begun to question the extent to which female partners of men who use Viagra and similar drugs are in fact happy with the results. First, a number of women are disappointed that they haven’t been included in outcome studies on drugs to treat ED since, they claim, sexual issues are as much a couples issue as an individual one. Some women also fear that Viagra will increase the chances that their partner will begin to have extra marital affairs. And, finally, some women aren’t happy about what they consider to be the excessive amount of sex their partners sometimes want after taking such medication. As one woman expressed it: “He’d kill me for saying this, but if he takes a tablet at night before we go to bed … we might have intercourse that night, then sometimes in the morning … and then if it doesn’t necessarily appeal to me I think oh no … he’s going to try again” (Moynihan & Mintzes, 2010, 139).

To summarize, then, while drugs like Viagra seem clearly to have an important role to play in the treatment of genuine erectile problems, difficulties abound: (1) the drug has been vastly over prescribed and is often used as an enhancement technology rather than a medical cure; (2) the marketing of the drugs have taken advantage of men’s vulnerability to be ‘manly’; and (3) the existence of the drugs has tended to reduce all sexual issues with men to mechanical issues that can be fixed easily, unproblematically, and exclusively by medication at the expense of a consideration of difficulties one might be having with self concept and with relationships. Finally, we could add (4) that these drugs have been tested in a particular context and for a particular population, and that their use to enhance normal sexual performance, particularly over long periods of time, is unknown. Moreover, use of these drugs can be dangerous when used in combination with illicit recreational drugs like ‘poppers’ used in the club scene (Moynihan & Mintzes, 2010, 140-141).

Given the enormous success of Viagra for men, pharmaceutical companies have been keen to develop a Viagra for women. Indeed, Viagra itself has been used by women as well. The general idea is that just as Viagra relaxes the smooth muscle tissue of the penis to allow it to engorge with blood during arousal, so too will Viagra relax the smooth muscle tissue of the clitoris allowing it to engorge with blood during arousal. But tests thus far have shown Viagra to work no better than placebo in women and so drug companies have searched for other medications (John Leland e al., 2000).

Part of the problem here is one we have seen before when we discussed female orgasm – assuming that men and women are essentially alike. As John Bancroft, the current head of the Kinsey Institute puts it: “We are still in a culture which has defined sexuality, sexual pleasure, and sexual goals in male terms. Then we apply the same paradigm to women. That is a mistake” (in Leland, et al., 2000). Think back to our discussion earlier in this chapter regarding what Masters and Johnson called the four stage “human sexual response cycle.” The DSM currently defines this cycle in slightly different albeit consistent ways as: (1) “Desire,” which “consists of fantasies about sexual activity and the desire for sexual activity;” (2) “Excitement,” which “consists of a subjective sense of sexual pleasure and accompanying physiological changes” such as erection in men and “vasocongestion in the pelvis, vaginal lubrication and expansion, and swelling of the external genitalia” in women; (3) “Orgasm,” and (4) “Resolution” (DSM IV-TR, 2000, 536). As we’ve noted above in our discussion of erectile dysfunction, Viagra works on what is here called “excitement” or what we might refer to as arousal mechanisms involving, in particular, blood flow. According to many researchers, men’s sexual “dysfunctions” often involve these mechanisms and so something like Viagra will work successfully for them. While we have argued that this line or argument is too narrow since men also suffer from other sexual difficulties, such as premature ejaculation (a problem with stage (3)) or with a lack of desire based upon any number of things mostly having to do with relationship problems, which is a stage (1) problem, it does seem that Viagra is a successful treatement for some men’s sexual problems. But women simply are different in this regard, and there is reason to believe that women’s sexual “dysfunctions” are more likely to do with stage (1) (desire problems) or stage (3) (orgasm problems) than they are with mechanical and physiological problems of stage (2).

Drug companies in fact attempt to play of the diversity of female sexual problems by defining female sexual arousal differently depending upon how a drug they are marketing works. “If Pfizer is promoting a drug that enhances blood flow to the genitals, then the condition might best be described as an ‘insufficiency’ of vaginal engorgement. If Proctor & Gamble is pushing its testosterone patch as a cure for women, the sexual disorder is discussed as a ‘deficiency’ of hormones. And if Boehringer has a pill that affects the mind’s neurotransmitters, women with low libido may have a ‘chemical imbalance’ in their brains. In a strange way, the disease seems designed to fit the drug” (Moynihan & Mintzes, 2010, 3).

Indeed, there is a whole class of what are called ‘designer drugs’ with which we are now quite familiar. Selective Serontonin Reuptake Inhibitors (SSRI) such as Prozac are the new drugs to treat “depression” and Ritalin is now used to treat “Attention Deficit and Hyperactivity Disorder (ADHD). These medications and the ‘diseases’ sprang into existence at the same time, and many researchers believe that the diseases were designed or constructed to fit what some drug treats (See, e.g., Stewart, 2000). Hence, no one is simply sad or energetic anymore, they are clinically depressed or suffering from ADHD. And one important difference between, say, sadness and depression, is that the latter is categorized as a medical/psychological condition that is to be treated through drug therapy. Drug companies, then, have a huge interest in having certain behaviors categorized as a disorder or a dysfunction, and then offering their medications as the preferred treatment option for the dysfunction. Female Sexual Disorder is the one of the latest ‘illnesses’ to be created in this way.

Carl Elliott (1998) has, along with others, explained the extent to which Big Pharma has become involved both in medical education and in research on the effectiveness of their own drugs. Moreover, they do this in a way that is not at all transparent by creating subsidiary companies to do their educational courses and research for them. Hence, it’s rarely clear that, e.g., a paper published in a scientific journal was actually sponsored by a drug company. Yet, as Elliott points out, more than half of the research being conducted on, e.g., the new SSRI antidepressants are Pharma sponsored, and the results of this research put these medications in a better light – more effective, fewer side effects – than non Pharma sponsored research. Psychiatrists and other health care professionals bear part of the blame as well. Over 50% of the people who are deciding what will be contained in the next edition of the DSM are on Big Pharma’s payroll (citation). And Steven Sharfstein, writing as the President of the American Psychiatric Association, acknowledged that “as a profession we have allowed the biopsychosocial to become the bio-bio-bio model.” As a result, he says, “a pill and an appointment” is too often the preferred (or only) treatment offered (Sharfstein, 2005, 3).

In their recent book, Sex, Lies and Pharmaceuticals, Roy Moynihan and Barbara Mintzes (2010) have detailed the ways in which Big Pharma has been behind the move to create a female Viagra. The first part of this process is to create a disease that they think their medication can cure. Indeed, in an interview in the documentary film, Orgasm, Inc., a drug company manager, Darby Stephens, states explicitly that Female Sexual Dysfunction was so new and unknown that, “In order for us to develop drugs, we need to better and more clearly define what the disease is… . We’re hoping to be able to expedite the process … of disease development” (Canner, 2009). Typically, the disease then gets defined in a broad enough way so that a great many people will fit into the category, even if their problem is slight and occasional. We certainly see this with respect to the various types of female sexual dysfunction listed in the DSM. “Hypoactive Sexual Desire Disorder” is defined as “a deficiency or absence of sexual fantasies and desires for sexual activity” (DSM IV-TR, 539, 541). And “Female Sexual Arousal Disorder” is defined as “a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement” (DSM IV-TR, 543). “The essential feature of Sexual Aversion Disorder is the aversion to and active avoidance of genital sexual contact with a sexual partner” (DSM IV-TR, 541). In all these cases, “the judgment of deficiency is made by the clinician.” Little wonder, then, that an article published in the prestigious Journal of the American Medical Association (JAMA), found that 43% of women suffer from Female Sexual Dysfunction (Laumann et al., 1999). This statistic was cited more than 1000 times in scientific papers and tens of thousands of times in the broader media (Moynihan & Mintzes, 2010, 44-45). Yet, this figure is completely misleading even given the broad definition of female sexual dysfunction. The figure came from a short series of questions posed to women asking them “whether they had experienced any of seven common difficulties for several months or more during the past year: The questions asked things like whether they’d lacked interest in sex, felt anxious about their sexual performance, had trouble with lubrication, failed to orgasm, came to orgasm too quickly or experienced pain on intercourse. By simply answering yes to just one of these questions, women were then categorized as having a sexual dysfunction” regardless whether their ‘problem’ was minor, happened just once, and caused them no distress. In fact, even the article mentioned a caveat that its results were “not equivalent to clinical diagnosis” of dysfunction (Moynihan & Mitzes, 2010, 46-47, 48). But this caveat was by and large ignored both by the scientific community and the wider public, as was the fact that its lead author was being paid by Pfizer, the drug company who marketed Viagra and who was also investigating treatments for FSD.

Hence, FSD is an example not only of a socially constructed disease, but it’s one that bears little resemblance to women’s actual experiences. To make matters worse, the drugs that have been developed to treat this ‘disease’ don’t actually do much to help women with their sexual ‘difficulties’ because these difficulties are rarely purely mechanical and physiological. More often than not they have to do with relationship issues and having to deal with the sorts of problems women typically have to deal with in the 21st century.

The medicalization of sex and the undue influence of Big Pharma is thus the most current problem facing sexology in its efforts to become a legitimate science. We need to follow the advice of Bullough, mentioned earlier, who suggests a multi- and interdisciplinary approach to the study of sex. In this way, we can guard against the sort of reductionist perception of sexuality as only, or even mostly, about physiology, and we also protect ourselves against the profit motive of companies looking to sell us drugs to ‘cure’ us from our physiologically based ‘diseases.’

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[1] These interviews could last for hours with the longest one lasting more than 17 hours. See Bullough, 1994, 174-175.

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