Doctors or horticulturists

Green fingers or pink Viagra? Female sexual dysfunction and medicalisation in
contemporary medical discourse
In January 2003, the British Medical Journal published an article by one of its resident journalists, Ray Moynihan, called “The making of a disease: female sexual dysfunction”. Moynihan wrote in this article that ‘A cohort of researchers with close ties to drug companies are working with colleagues in the pharmaceutical industry to develop and define a new category of human illness at meetings heavily sponsored by companies racing to develop new drugs.’ Encouraged by the success of Viagra to ‘build similar markets for drugs among women’, companies need ‘a clearly defined medical diagnosis with measurable characteristics to Moynihan criticises the dominance of industry figures in processes of consensus creation, the methods used to gain prevalence statistics, and the hyping of these statistics by clinicians and the media. He also introduces us to Irwin Goldstein, a professor of urology and gynaecology at Boston University School of Medicine who is a prominent figure in the international work on FSD, having chaired all three meetings, between 1999 and 2001, of the Female Sexual Function Forum, which aimed to develop consensus on FSD. When asked at a New York conference about criticisms that sexual problems may not be best dealt with by doctors, Goldstein replied: ‘Who’s best equipped to deal with it? The horticulturists?’ And when asked whether marketing campaigns worth millions of dollars can amplify certain views of sexual difficulties and promote some therapeutic options over others, he said ‘I’m an academic clinical doctor. That’s a question for some philosopher’.
Goldstein’s responses point to some of the interesting bones of contention in the debate about FSD. For much of the debate is precisely about who is equipped to deal with the problems of sexual dysfunction, and this question in turn hinges on views of what sort of thing it is, what it is caused by, and what sort of solutions to it are appropriate. Through the cacophony of voices to be heard in the debate, I am going to extract mostly those of the most vocal and public group – the coalition of urologists and pharmaceutical companies alleged medicalisation of sexual problems. 1 Moynihan R ‘The making of a disease’ BMJ 4 January 2003, 326:45-47 2 Moynihan, op cit, p 47. 3 And sexologists? Check. Female sexual dysfunctions and medicalisation
The DSM divides both men’s and women’s sexual problems into four categories of dysfunction: sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders. While family therapists, for example, acknowledge a multiplicity of physical, social, and psychological factors in sexual dysfunctions, the public is increasingly being encouraged, by the influential marketing drives of pharmaceutical companies, to think of “female sexual dysfunction” as a unitary disorder that is overwhelmingly physical in nature and cause, and for which pharmacological treatment will be the much-needed solutionn of critics of this tendency makes up the anti-medicalisation critique. The concept of medicalisation has been invoked frequently in the last 40 to 50 years. That it retains a contemporary currency and is still at the heart of debates about medicine is evidenced by the profusion of newspaper and magazine articles about health and disease which refer to or use the notion, and the British Medical Journal’s 2002 themed edition called Too Much Medicine? which was on the whole highly critical of unchecked medicalisation and encouraged a re-evaluation of what we think of as disease. Contemporary concern about medicalisation has to be understood against the backdrop of anxieties about modern Western medicine – about its technological power, its increasingly bureaucratic and impersonal nature, and the ethics guiding research and technological capacities such as the new genetics. These worries are not unlike those sustaining the anti-medicalisation critique in the sixties and seventies, when high-profile scandals such as the thalidomide disaster and the Tuskegee syphilis trials prompted charges of paternalism, deception, and ethical failure in treatment and research. Much of the critique of medicalisation in the last 30 or 40 years emerged from medical sociology. Diagnostic categories were seen as labels, and means of social control, for deviant members of the community flouting a culture’s behavioural norms. The critique of medicalisation in the sixties also overlapped with anti-psychiatry, which combined a suspicion of institutions with a critical perspective on the medical model of mental illness; its expansion; and sometimes brutal treatments these supposedly justified. 4 Insert lines about pharmaceutical and medical discourse about FSD; the DSM’s consecutive descriptions of FSD; the relationship between the FSD we know through the media and pharmaceutical companies, and the FSD in the DSM which is more differentiated. What are the differences between DSM categories before late 90s, and late 90s consensus work which Moynihan and Tiefer criticise? Also think about pharmaceutical interests in creating association between one kind of cause, one kind of disorder, and one In the seventies, scholarly work on medicalisation flourished, with seminal works on childbirth, hyperkinesis, and alcoholism. This work claimed that personal and social life was being increasingly viewed through the prism of scientific medicine and its problems categorized as diseases; that the financial, political and technological resources of institutions guiding this process made its motivations suspect; and that questions of social inequality were being deflected into the context-free realm of pathology. The assumption of ‘medical imperialism’ typical of this work, with its medical profession characterised as one arm of a state wielding power over the reluctantly ‘medicalised’ came under sustained attack by the work of Michel Foucault, whose writings enabled an explanation of the undeniable complicity of the public in medicine’s growing jurisdiction. Foucault’s power, dispersed through social systems, and providing guidelines about how patients should understand, regulate, and experience their bodies, suggested that society is medicalised in a profound way, monitoring and administering bodies of citizens in an effort to regulate and maintain social order as well as to promote good health and productivity. With an all-pervasive ‘clinical gaze’, a simple attribution of power and passivity was undermined; patients instead became active participants in a discourse about the medicine and its alternatives. My concern here, however, is to consider the conception of medicalisation in the more popular debate. Several strands of concern are worth disentangling as follows: ™ A concern with social control - of "deviants" (homosexuals, schizophrenics) or groups traditionally seen as inferior (women, ethnic minorities) through labelling, coercion, or treatment; ™ a concern with the transformation of non-medical problems, or non- diseases, into medical problems or diseases. Here, problems that are personal, social, political or economic are made into medical ones. Likewise problems that are simply a normal, inevitable part of life are made into medical problems. (Examples in the literature include social anxiety disorder, FSD, the menopause, PTSD, Gulf War syndrome, gender dysphoria, ADHD, obesity.) ™ a concern with these transformations as legitimising often costly medical treatments and solutions rather than personal, psychological, relational, social, or political solutions, or cheap physical solutions such as diet and ™ a concern with pharmaceutical companies and financial interests as driving the extension of medical and psychiatric diagnoses and treatment. These interests raise questions about both the need for treatment and its ™ A concern that increased medicalisation encourages an unhealthy obsession with health and disease, discourages individual responsibility, and fosters an expectation of a life free from risk and misfortune. The coalitions that form, however, are complicated in their configurations. Two broad groupings can be discerned. The first is critical of the institutions of medicine; its diagnostic expansion is a worrying political trend, in which a physical and technological fetishism effaces the role of a multiplicity of social, political and economic factors in bringing about disease, and casts individuals subject to complex experiences as faulty machines to be repaired by experts. The second grouping tends to focus on the dubious pathologisation of virtually every disappointment and misfortune in life. Sceptical of experiences such as stress and anxiety wielding causal powers in disease development, this view understands disease as paradigmatically physical, and such psychological states as somehow not truly physical. Without the same ontological “reality” as physical causes, psychological factors lack the causal agency physical factors enjoy.
Medicalisation as transformation
A central element of the anti-medicalisation critique is the notion of transformation of non-disease into disease. This concept, however, depends on a prior understanding of the distinction between disease and non-disease, for without the latter, how do we know when a problem has been wrongly identified as a disease? And yet problems abound with definitions of disease and non-disease. Many definitions rely on concepts of biological normality and abnormality; but often fail precisely because our interests as persons do not always coincide with our biological interests as animals. What is more, the focus on normal function can lead to a disregard for the considerable functional variability that undermines this very focus. More generally, philosophical attempts to distinguish between disease and nondisease are often prompted by a desire to resolve ethical and political questions about resource allocation, treatment versus enhancement, and new genetic interventions. But since biological accounts of disease often end up detaching the concept of disease from considerations of what we think is undesirable and harmful, these armchair musings are of little use. It is not just philosophical attempts to define disease and non-disease in relation to abnormality and normality that falter. Medical quantifications of the menopause involve comparing physiological measures of older women with those of "healthier", young women, taken to be normal. This involves defining from the outset those bodily changes occurring alongside ageing as diseased, and defining what is healthy as those characteristics prevalent in youth. And yet the idea of the healthy ageing person makes perfect sense. And while hormone levels and bone density measures of young, healthy women may be statistically normal, it is not clear why statistical normality should equate to non-disease, or statistical abnormality to diseaseexacerbated in psychiatry, where shading from normal abnormal behaviour render difficult most diagnoses of, for instance, ADHD. None of these problems, of course, comes as a surprise, for such definitional attempts are hostage to the illusion that our concepts of disease both are, and should be, separate from the social context in which they operate; that they have a life and reality of their own, separable from their meaning, use and operation in a particular cultural and historical moment. And the concept of medicalisation as transformation only gains a foothold against the background of an assumption that a disease is a discrete, categorical state radically different in kind, and not just in degree, from states of non-disease or states of health – an assumption that is widely held but not uncontested, and certainly not age-old.
From a poll on what counts as a disease, the BMJ collated several classes of non- disease; one in particular, non-diseases of end of spectrum (which included ADHD and chronic fatigue syndrome), typifies the kinds of conditions that until the mid-19th century would have been bona fide diseases. Along with the other classes - non-diseases of universality (ageing), of usual response (hangover) – it points to the assumption of a 5 Look up BMJ article about this; statistically normal in what sense? amongst which population? Surely not older women! 6 It is not enough to point, in order to undermine the validity of current concepts of disease, to point out historical change; a confidence in current medicine as embodying progress and corrections scuppers any such attempt. One needs to show also that contemporary consensus is not so clear, even synchronically. The orthodoxoy of the categorical view is indeed besieged by problems (cancer, nutritional disease, immune system, and psychiatry.) categorical difference in kind between disease and non-disease only relatively recently become something of an orthodoxy. In psychiatry especially, a view of disease as the result of a combination of internal and external pressures was arguably predominant until efforts to chip away at psychiatry’s eclectic and dynamic framework, from the late fifties onwards, opened the way for the requirement of categorical difference. This dynamic view still has much purchase in various branches of psychiatry and psychotherapy, and debates about the validity of the DSM editions, and about the more psychoanalytically-inspired psychotherapies, are essentially about this requirement. And protestations against the requirement in medicine regularly resurface; the psychosomatic medicine movement, with its contemporary heir in psychoneuroimmunology, sought to re-establish the view of diseases as points along a continual spectrum of functioning. Clinical experience and practice, moreover, arguably also employ a more fluid conception of the distinction between disease and nondisease, possibly influenced by the newer challenges of cancer, AIDS, and nutritional diseases. The point, however, remains that contemporary biological psychiatry and medicine place a significant burden on the concept of disease as delineating a discrete condition; and that without such a view, intuitions about medicalisation might be very different indeed. The problem of dinstinguishing between disease and non-disease also faces those untroubled by medicalisation. Indeed, it faces anyone who seeks to claim that something is “really” a disease or not. But my point is not that there is no sense in the transformation claim; it is rather that if we hold that it is only “real”, brute biological fact which determines whether something is a disease, rather than seeing this decision as subject to pragmatic, social and ethical determination, then all definitional attempts to ground the claim are curiously academic. The uses and applications of the disease category are permeated with pragmatic, moral and cultural views about what sorts of conditions are bad and worthy of treatment; about the role of misfortune and individual responsibility in etiology; and about the economic ramifications of a disease category. We can decide that anything is a disease; it just depends what our concerns are. We could categorise as diseases all conditions causing dysfunction and distress; we would just have to face the consequences in terms of service provision and insurance cover. The fact is 7 Relate the relatively recent requirement of a universal and specific etiology to the requirement of a categorical difference between d and non-d. that we limit, pragmatically, the extension of the disease category, making decisions case by case, depending on treatments available and cultural perceptions of conditions Importantly, our views about what counts as a disease are infused with assumptions about what sorts of causes should be included in narratives of disease development. Thus we saw earlier that one strand of impatience with the ever-increasing number of diagnoses stems from a suspicion of the causal and physical agency of psychological experiences. And assumptions about what are legitimate causes are significantly moulded by a confluence of social, cultural, political and aesthetic views about what sort of stuff exists in the world, what kind of entities form part of a scientifically legitimate medicine, and what are scientifically appropriate means of finding out about them. The metaphysical and epistemological commitments of modern medicine, that is, with its commitment to some conditions and dismissal of others, thus need to be understood from a historical and sociological perspective. It should now be clear that my work on FSD forms part of a larger interest in understanding the historical, social and cultural conditions shaping our preferences for certain types of causes over Technology, treatment and megabucks: the ethics of medicalisation

Other aspects of the medicalisation critique are mainly fuelled by, firstly, concerns about the precursors to the framing of conditions as diseases: what interests determine this process? Do pharmaceutical companies’ interests compromise public health? And secondly, critics worry about the cultural, economic and political ramifications of the notion of disease. What are the implications of disease labels as regards causal understanding? Do they discourage a focus on a narrow range of causal factors – specific pathophysiological factors at the expense of socioeconomic and psychosexual factors, for instance? And do they encourage a non-reflective endorsement of medical and pharmacological solutions, which may be of little help to patients, and 8 There are reasons to believe that current thinking about medicine leads to a situation where, if a treatment is available for a condition, then, in order for that intervention to count as an acceptable medical treatment rather than a morally dubious enhancement technology, the condition tends to be recast as a disease. There are interesting and important questions here regarding our ambivalences about ‘enhancement technologies’ and lifestyle drugs. could even be of some harm, with other treatment options, related to social and Critics of medicalisation often hold the view that certain social and cultural phenomena can both affect, and be reinforced by, the trend to medicalisation. One example is the desire for a quick fix. A second example is the view of sex and sexuality as defined comprehensively and exclusively by biology. Sex, contained by biology, is thus a natural act, a capacity for which lies deep within us and needs only be effectively elicited. The biological determines behaviour, and implies unchangeability and imperviousness to environmental, social, and contextual factors. Sex and sexuality exist independently of a relationship, and sex is simply the smooth operation of complex component parts. Sexual dysfunction therefore has everything to do with our biology, and not with our selves as more complex, situational, wholes. And its resolution is thus to be sought in a high-tech and impersonal repair job. The success of technological interventions in dysfunction is measured by objective technologies evaluating, for example, the degree of engorgement or erectile rigidity. Human, subjective variables in measurement and evaluation are excluded; and yet, in sexual matters, measures such as “satisfaction” and “happiness” may be more than relevant. After all, there are many ways in which to get our kicks. Indeed, several studies suggest that sex therapy can lead to improved satisfaction and happiness with sexual lives even when “technical” problems have not been successfully resolvedour definitions of sexual function? Thinking about sex often focuses on the genital and the coital. Feminists especially have criticises the tendency to narrow the spectrum of sexual possibility to genital performance, with Freud singled out as the prime culprit, given his emphasis on the need for women to progress from clitoral sexuality to vaginal sexuality. But where does this genital and coital focus come from? The classifications in the DSM, which embody this tendency, hark back to the work of Masters and Johnson, who in the 60s and 70s, described a universal, four-stage human sexual response cycle - an inborn programme, common to both men and women, 9 It is important to note that the concerns I outlined above (on p 3-4; show OHP?) can operate independently of one's views about the transformation of non-diseases into diseases. One can, for example, be unsure about the wisdom of developing a female Viagra for female sexual dysfunctions, even if one does accept the validity of the category. 10 find reference in Tiefer. Tiefer’s analysis is a trenchant and sharp analysis of the flaws within contemporary sexology. Some of her descriptions of the work of Masters and Johnson, however, is a little narrow; she tends to caricature Freud through the views of his disparate heirs; and some of her assessments seem to derive from a desire to give sex therapy a respectable platform. What is sex therapy contrasted with? Sexology? The implications of DSM? See Tiefer 56-57. working like a mechanical clock as long as “effective sexual stimulation” is present. Leonore Tiefer has argued that only subject selection biases made it possible for the researchers to claim to "discover" this universal cycle, and moreover that, given the definition of "effective sexual stimulation" as that stimulation which facilitates the response conforming to the cycle, the alleged discovery of this cycle as the bedrock of sexuality is revealed as methodologically over-determined. In the DSM, this cycle becomes the standard of human sexuality, deviations from which become the essential The DSM also incorporates an attempt, again influenced by Masters and Johnson, to emphasise parity of both sexual function and dysfunction between men and women. Tiefer is unhappy with this: “The construction of gender in the official psychiatric sexuality in nomenclature is easily summarised: men and women are the same, and they're all men.” Emphasis on parity, she argues, impoverishes an understanding of the causes and treatments of female sexual dysfunctions, through the occlusion of the social inequalities which mediate women’s sexuality The sexual dysfunctions in the DSM are overwhelmingly about genitals; sexual aversion, for instance, is aversion to the genitals. ( check that) Its nosology implicitly prioritises reproduction as the primary purpose of sexual activity; sexual functioning is full genital performance during heterosexual intercourse a rhetoric echoed in medical and pharmaceutical views, as well as by patient activistsconveyed by a casting of it as a technology to resolve problems in monogamous, heterosexual relationships; any connotation of it as a lifestyle drug designed to satisfy the insatiable urges of a promiscuous – and possibly homosexual - male population was consistently distanced. Similarly, women with FSD are represented as needing pharmaceuticals in order to fulfil their potential as sexual partners within heterosexual relationships, not as lesbians and certainly not as solitary users of aphrodisiacs or sex toys. Previous attempts to represent a clitoral therapy device (the “Eros”) as a medical device involved descriptions of it as a device for stimulation, but not for direct sexual satisfaction. Not intended to replace a partner or a penis, it enhances one's ability to 11 Interestingly, the inability to experience the normative sexual response cycle then comes to represent a disability in the area of sexual functioning, "whether or not the individual was distressed by the symptom". (Spitzer, Williams, & Skodol, 1980, pp. 153-4) 12 This debate about parity needs to be understood within the framework of shifting views within feminisms about the values of emphasising sexual difference and sexual parity. 13 . See also Margaret Jackson, who claims that sexology’s role, historically, has been to normalise and universalise the coital imperative and the primacy of penetration. achieve orgasm, rather than being able to produce orgasm. For use without one's partner; it addresses female sexual capacity; male sexual performance is not at fault. It represents the obverse of Simone de Beauvoir’s quip that “Il n’y a pas de femmes frigides, il n’y a que des hommes maladroits”. Women using what is essentially a sex toy do not need to feel that they are evading their relational responsibilitiests in sexual technology, from drugs for venereal diseases to birth control pills, have indeed historically been represented as means not only to address medical problems but to reinforce the institutions and norms of heterosexual relationshipsif medical, are unthinkable as autoerotic or promiscuous technologies. Given this tendency to focus on sexual technologies in terms of monogamous relationships, it is all the more interesting that sexual function and dysfunction are considered problems of the isolated, physical individual. Relationships are not key to the genesis of sexual disorders, and nor are they relevant to their treatment. And yet they are its beneficiary. It is in their name that medicine forayed into matters of sex. Of course, the occlusion of relationships in treatment was not always the case: Masters and Johnson’s therapeutic endeavour was indeed a kind of intimate horticulture – one that provokes much mirth in today’s technical world of little blue pills.
The popular rhetoric of sexual dysfunction is, however, increasingly about personal happiness and fulfilment. Again, this aspect of sexual discourse – of sex as a central aspect of ourselves in need of voicing, whose repression can lead to mental, physical and social disorder – has a respectable history. Historians emphasise the growing importance of sexual relationships to identity, and Tiefer notes the dangers inherent in this view if accompanied by a biological reductionism. And yet self fulfilment through sex is discomforting; it threatens the triumph of individual pleasure over social and familial containment of it, while also opening the door to troubling lifestyle drugs. All the more, so given our ambivalence about drugs that work on many conditions (e.g. Prozac) and that work on ‘normals’ as well as people with diseases (Ritalin) – an inversion of earlier views that ill-specific drugs were a sure sign of quackery. Misunderstandings of medicalisation

14 Fishman, J.R. & Mamo, L (2001): “What’s in a Disorder: A Cultural Analysis of Medical and Pharmaceutical Constructions of Male and Female Sexual Dysfunction”, in Kaschak, Ellyn & Tiefer, Leonore (ed.) A New View of Women’s Sexual Problems, pp. 179-195; New York, Haworth Press 15 see Jeffrey Weeks, Robert Nye, Angus McLaren etc. 16 What about sex therapy now? Women’s magazines etc. In the excitement over Viagra – fuelled by a collision of the increased importance of lifelong sexual activity, the expansionist needs of specialty medicine and medical technology, and the dominant male sexual script – it was frequently claimed that psychogenic impotence had been oversold and that organic causes of impotence were much more common than previously realised, a claim which captivated the media and legitimated the increased medical involvement in sexuality. This process revealed many interesting assumptions and equivocations, visible also in the debate about FSD. In response to Moynihan’s controversial BMJ article, a nurse therapist wrote that FSD is not a ‘new, pharmaceutically manufactured condition’, and that it is ‘ignorant in the extreme’ to think that she and other nurses in the country are ‘only treating “social disorders”’. A private consultant wrote that Moynihan’s article ‘trivializes the real suffering experienced by millions of women’. One patient denied that ‘sexual dysfunction is a fabrication of their (and the pharmaceutical industry’s) imagination’. Another patient wrote that a woman is ‘effectively silenced by the constant response that it is psychological (i.e. that she is imagining it).’ Here, the sociological critique of the construction and use of a diagnostic category is thus wrongly interpreted as a claim that the illness and symptoms experienced by patients are not real, not physical, not important, not distressing, and not necessarily in need of treatment. Doctors also frequently respond in this way, reiterating the reality of the condition, insisting that women are not ‘imagining’ their symptoms, and underlining the correctness of the diagnostic category. But the sociological critique is not necessarily making a claim about people’s symptoms or the physiological processes underlying them. Rather, it is drawing attention to the cultural and social influences on, and ramifications of, viewing conditions as diseases and endorsing medical interventions. (It does sometimes deny the validity of a category, but even that is not equivalent to denying the existence or reality of the condition.) Moreover, responses to the critique reveal an assumption that psychological factors, for instance, can have no causal agency. They also reveal a feeling that if a technological treatment of an ill exists, this treatment vindicates the ‘reality’, organicity and physicality of the condition - a conviction that medical treatment and complex, psychosocial causation are mutually exclusive, and that “real”, physical causes warrant medical treatment. Similarly, it is assumed that if a technology exists which acts on a certain process, then that process is the causal factor in the condition. What is evident here is a considerable confusion about what sorts of objects and processes can be part of a legitimate scientific medicine. What would it mean to include social and psychological processes in a causal story about FSD? The popular answer to this is that it would undermine the scientific nature of FSD and the disciplines investigating it; the authenticity of claims of suffering; and the legitimacy of treatment. One could tell a story here about the historical fragility of the scientific status of sex research, where the emphasis on the biological is part of a campaign to bring sexology into the scientific fold. But this too is an aspect of a wider ambivalence about how to preserve medicine’s hard-won status as a scientific endeavour, where the determined introduction of multiple causal entities - whose physical presence and agency is dubious - would be to endanger this status. Given this ambivalence, it is clear that popular discourse about FSD both expresses and entrenches the view a preference for physiological causes and solutions. The emphasis on the physiological by the pharmaceutical industry, and the sex researchers it has formed alliances with, sustains the feeling that psychological and social factors are suspect, and that physiological ills and pharmacological solutions are natural bed-fellows.

Source: http://www.inter-disciplinary.net/ptb/mso/hid/hid3/angel%20paper.pdf