Feminists with FSD does Orgasm, Inc.

10/12/2011 at 10:51 pm | Posted in Uncategorized | 5 Comments
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It’s the post you’ve all been waiting for and the one I’ve procrastinated on for far too long.

Gather ’round readers and gender studies students (because I know that you’re going to watch this sooner or later for class,) and behold an opposing view of the sexual dysfunction documentary from someone who actually has female sexual dysfunction.

I’m not doing a chapter-by-chapter breakdown of what happens during the film; you can find that elsewhere. Today we’re going to look at problems and places for improvement in the film. Some problematic elements with the fim are intrinsic to the philosophy the director embraced, others are problems of omission: Viewpoints left out, intersectionality not explored, things that should be investigated further.

- Orgasm, Inc.’s alternate title could be,Sex is not a Natural Act, abridged version. If you’re short on time and want to learn about the feminist social construction perspective of sexual dysfunction, then the film will be a time-efficient crash course. To most uninitiated viewers, the film will entertain and present new information. I’ve already heard Orgasm, Inc’s. arguments regarding the history and validity of sexual dysfunction elsewhere, so I spent most of the 80-minute film bored to tears.

What’s the social construction perspective of sexual dysfunction? Basically, everyone’s sexuality is shaped by culture, and sexuality is varied with a wide range of normal. But the deck is stacked against the ladies, due to gender roles, restrictions on reproductive rights and misogyny. Under social construction, what might be called sexual dysfunctions are better identified as sexual problems – understandable, if annoying, responses to crappy circumstances. Most women’s sexual problems are social in origin, (stress) and can be addressed with broad changes – and some individual lifestyle changes. This is all well & good for most women.
Contrast this with the medical model of sex, which sees sexuality as a natural phenomenon, acted out in a fairly rigid series of steps (arousal, plateau, orgasm, resolution.) Problems expressing sex (performance) are viewed as dysfunctions from the norm, stemming from organic imbalances that can be addressed at the individual level – using medicine. But even under the medical model, most people are generally healthy and can perform sex.
No matter how you slice it, most women don’t have sexual dysfunction.

- Who is Orgasm, Inc. for? Who did Canner choose to interview? What audience did Canner have in mind? Whose care is prioritized?

Prominent interviewees include sex educators Kim Airs and Carol Queen, and neuroendocrinology professor Kim Wallen. Most of the interviewees included in the film represented members of the medical industry. On the flip side, Canner spoke with journalist Roy Moynihan and representatives of the New View Campaign, an activist organization which takes a social construction perspective of sexual dysfunction.

Orgasm, Inc. is for most women; the ones without sexual dysfunction. Liz Canner is deeply worried about the well-being of normal, healthy TAB women. Unfortunately the film left me feeling isolated, as one who actually does have and sought treatment for sexual dysfunction. Interviewee Moynihan states, “There’s a lot of money to be made telling healthy people they’re sick,” as recently recognized (if still contentious) diagnoses such as restless leg syndrome and social anxiety disorder scroll across the screen. The concern is that if Big Pharma can create the perception of a disease (that must be addressed,) and develop treatments, then there’s potentially billions of dollars worth of sales to be made. This quote prioritizes protecting the majority from Big Pharma, rather than prioritizing care for the largest minority, especially if we pause to recognize that many medicalized conditions are real – just invisible, and poorly understood.

# of interviews with someone who identifies as having female sexual dysfunction: Unknown. Liz Canner interviewed four non-professional women about their experiences with sexual problems. Of these, only one, Charletta, identified as having “A disease,” referring to FSD. Upon learning that most women require clitoral stimulation to reach orgasm during intercourse, she changed her mind and decided she was normal after all.
The film juxtaposes Charletta’s interviews with commentary about how most women reach orgasm, with the implication that Charletta never had FSD to begin with. Canner comments, “Charletta was enrolled in a study for women with FSD, despite the fact that she was healthy.” Yet clearly, Charletta identified as having FSD at one point and was upset about it – after all, no one wants to be considered diseased, right? Disease and mental illness and disability are bad things to have!
And then, she dropped it from her identity.
I won’t speculate as to her status. Rather, it is my firm belief that a valid alternative way to address the stigma & distress Charletta felt from identifying as having sexual dysfunction, is to recognize that it’s okay to have sexual dysfunction. Stigma need not be intrinsic to sexual dysfunction, it comes from outside sources. From where? Well, I’m not the only one who notices that there’s quite a lot of limp and small dick jokes in the media – a social force rather than medical.

It may be worth noting that during an interview with the founder of the pharmaceutical company Vivus, Virgil Place said he created the company after developing erectile dysfunction after undergoing a radical prostatectomy for cancer. This may be the only other person included in the film who openly identified as having sexual dysfunction – of the male variety.

So, why choose Charletta? Critically, she was one of 11 patients in a test of Dr. Stuart Meloy’s sensationally-(and un-originally)-named Orgasmatron. It’s surgically installed hardware that sends sends electricity through the body, with the goal of inducing orgasm. It reminds me of a TENS machine for pain management, though more invasive. This makes sense, because the device was originally designed for chronic pain patients and sexual stimulation was a side effect. Furthermore, the risks associated with surgical implantation of the Orgasmatron are derived from the Safety Information sheet about using Neurostimulation Systems for pain management. (The director makes no comment as to what decisions chronic pain patients should make when considering electronic stimulation for pain management.) Since installing the Orgasmatron involves surgery and potentially serious side effects, it’s an extreme measure. Nonetheless I can still see a potential application for some interested patients.

It took surgeons twice as long to install the Orgasmatron into Charletta’s spine as it did with other patients, and then it did not work as intended. She had to have it removed.

So what happened to the other 10 patients?
According to Dr. Meloy, the device stimulated 8 of 9 patients, or 10 of 11 patients (I don’t know why two figures are cited.) 6 of the women in the study kept the electrodes in. And “It worked” (Meaning it induced orgasm?) in 4 of those 6 patients.
So why don’t we get to hear the first-person accounts of these women? What’s going on with them? Unfortunately we’re not likely to find out any time soon, as I have yet to find Meloy’s peer-reviewed primary source journal study.

- # of times we learn about dyspareunia/sexual pain/chronic pelvic pain: 0.
Even though Dr. Leonore Tiefer has stated that dyspareunia is the only valid & important female sexual dysfunction, (a problematic statement with which I disagree,) Orgasm, Inc. doesn’t talk about it. How painful sex fits in with the critique of sexual dysfunction and pharmacological treatments (often off-label) broadly remains unknown. The film addresses pleasure, orgasm and arousal, but not pain, and certainly not other overlooked sexual problems. It’s another cop-out.

- Orgasm, Inc. criticizes the famous and questionable statistic that 43% of US (cis, I presume) women have some form of female sexual dysfunction. Even I agree that number is overestimated. But there was a subsequent 2009 study that included “Personal distress” as a criteria for sexual dysfunction, and using this modifier, the statistic revised downward, to some 12% of the US female population having a form of sexual dysfunction. And that’s only if we completely exclude dyspareunia from the definition of FSD! I still wonder whether the raw numbers really matter – if only 12% of the population experiences FSD, is that small enough to make it real?
In fairness, Canner did most of her filming prior to 2009. The new study came out too late for the filming, but could have been included with the DVD extras, which include documents through 2010.

The film’s coverage of genital surgeries is brief, but that 5-10 minutes encapsulates serious feminist critique. I never know how to address this topic, because I went through vulvovaginal surgery. And although I’m ambivalent about cosmetic surgeries, I hate the way almost all discussions about it go – including Orgasm Inc’s. 
The film makes no commentary on genital surgeries done for health reasons (cancer, vulvodynia, burns & injuries, etc.) or for bottom surgery for trans* people. Feminist discussions of genital surgeries usually exempt from critique genital surgery done for “Medical reasons,” whatever that means — medical needs are rarely defined. What scares me is there’s this binary, where surgery for medical reasons is “Okay,” and for asthetic reasons is “Not okay.” So what happens if someone undergoes genital surgery for reasons of both looks (or insecurity) and physical well-being – that person is likely to have to prove to an outsider’s satisfaction, that their procedure was in fact medically mandated. Canner focuses exclusively on non-medical surgeries, as a husky voice whispers, “Sex surgeries.”

“Sex surgeries,” eh? Maybe it’s not as medical and acceptable as I thought it was after all. This phrasing presents me with a unique problem, because the vulvar vestibulectomy allows me to have sex – theoretically, anyway; in practice, it’s a bit more complicated. Since I experienced pain, we can probably consider this a “Medical” surgery, but my life was never in any direct danger. VVS was not going to kill me, though it did depress me and send me into a dark place Idon’treallywanttotalkaboutrightnow. Theoretically, if I never attempted vaginal insertion of objects ever again until the day I die, then I might have been able to go my whole life with minimal discomfort. So since I could have made some lifestyle modifications instead, were my reasons for surgery still medical enough? Or is what I had just another sensational “Sex surgery,” yet another form of FGC?

Canner cites an editorial in the BMJ comparing cosmetic genital surgeries to female genital mutilation, and like many peer-reviewed articles & editorials, it generated critical responses. Responses brought up the difference between genital cutting forced upon young girls without their consent, whereas plastic surgeries are actively sought out by consenting clients. Other responses raised concerns that the comparison draws attention away from FGC globally.

That’s all I’ll say about the film’s coverage of genital surgeries for now. Although I’d like to talk more about surgery, I don’t even feel comfortable getting into my own experience on this blog.

- The critiques of sexual medicine apply to the medical industry broadly. Of course a movie about medicine and sexual dysfunction focused only on sexual medicine. However, most of the critiques about Big Pharma’s involvement in shaping medicine apply to the field broadly.
Canner et al address problems inherent in the growth of modern medicine, including a for-profit motivation, direct-to-consumer marketing, defining what it means to be sick and well, and financial conflicts of interest between doctors/researchers & pharmaceutical companies. I noticed that Vivus staff talked about the influence of stock market speculation as a driving force behind drug development, which in light of the current US recession & Occupy Wall Street protests and who is most likely to actually have stock in the first place, makes me go “Hmmm.” These are systemic problems, inherent in Big Medicine itself. As such, it’s going to take systemic changes to the healthcare industry in order to rein in corporate greed and improve patient health.
It becomes a delicate balancing act though, when we recognize that these systemic changes have to occur in such a way as to minimize harm to current and future patients who need and benefit from medical interventions. We can’t outright kill Big Pharma without there being casualties at the individual level. Canner’s DVD extras link to a few organizations that viewers can get involved with in order to critique Big Pharma, however, I myself am not comfortable with the tactics employed by one of the most vocal activist groups.

- Orgasm, Inc. does not address the stigmatization of sexual dysfunction, a stigmatization which regrettably the film contributes to.
I am constantly dismayed when I see arguments against the validity of sexual dysfunction broadly get used at the individual level to invalidate women’s experiences with sexual problems – to jeer, to crack jokes, to partner-blame. I fear that a woman who identifies as having sexual dysfunction won’t be able to talk about it, because someone more enlightened will refuse to believe her – and will instead ‘splain why she is so deluded and gullible and brainwashed. I have this fear, because that’s exactly how I feel when I try to talk about FSD on any blog other than my own. This already happens.

If you seek medical treatment for sexual or other health problems, then you are doing something bad and wrong. This is made abundantly clear with Orgasm, Inc’s. theme song lyrics, “Sex Pill! I need those poisons baby!” and when interviewee Kim Airs explicitly states, “The whole thing with taking drugs, for this or that, my belief is, living for [or 'we live in?' Didn't quite catch that - K] a drug-free America. I mean, don’t take drugs!”

Is this really the ideal America to strive for? The US war on illegal drugs reveals that enforcement disproportionately targets people of color. It also holds back potential treatments for some disabilities, leading a few states to legalize marjiuana. Patients with prescription drugs can get legally and medically busted, too. Legal use of prescription drugs for this (depression?) or for that (chronic pain?) is already sneered at by many (including some folks in my own family) with dangerous consequences to those who need the meds. (She didn’t say what this or that is.) So now we have people with chronic pain conditons who have to jump through hoops & present themselves “Correctly,” in order to not appear as a junkie. So some folks have to live in a drug-free America whether that’s what they need or not.

Some interesting areas for discussion were not explored; perhaps a budding documentarian is reading this and will run with it. The film does not talk about sexual dysfunction treatments + insurance. In the United States, there is an ongoing healthcare financial crisis. Millions of Americans – the figures range between 44 million to almost 60 million – are without health insurance, or spent at least part of the last year doing without. Recent news tells us that those who do have health insurance face increased out-of-pocket costs. Meanwhile, government safety nets for the poor are seeing their budgets cut. So there’s no word on folks who may consider themselves to have sexual dysfunction, but who cannot afford to seek treatment. This is something I’m facing right now, as I need to go get physical therapy again and can’t afford to pay for the deductible.

So if you can’t afford medical treatment, then that’s good, right? Now you must focus on non-medical interventions, which have fewer side effects. Hold that thought – remember that it is possible to seek non-medical intervention for sexual dysfunctions, such as talk therapy with a licensed sex therapist or psychologist, and to have such costs be partly covered by insurance. The blogger Minority Report has written about taking this route, and she’s done some math. Talk therapy can become pricey, and even sex therapists themselves express disappointment with the outcomes. I have no doubt that there’s a connection between deregulation and the privatization of healthcare (insurance,) but I do doubt that I can explain it here. (That hasn’t stopped me from trying, though.)

Orgasm, Inc. final thoughts:

- Do you still want me to do a play-by-play review?
– Do any regular readers here want to write a review as well? Maybe you saw it and just <3 it idk
– So basically, we have a movie here about FSD, with either minimal or zero representation of folks who actually have FSD (depending on how we look at Charletta.) We have an old guy with ED and one lady who decided she’s totally fine in the end.
– I’m hearing people talk for me, but not using an accurate reflection of my own voice.
– How much unchecked privilege do you have, that you can protest the very existence of a health problem, with no room for any exceptions, when there are people going, “Hey, I think something is going on over here I need medical help with”???
– I am still not convinced that FSD is an invention created by Big Pharma, nor that there is no place for pharmacological options for sexual problems.
– I am still wary of the social construction model of sexual problems.
– I am still wary, because it’s supposed to address weaknesses in the medical model, but it has its own fucked up weaknesses and all it does is fuck up in new ways. Like it tries to address blanket statements in the medical model, but then it just creates new blanket statements.
– I am certain that viewers will approach this blog to ‘splain to me how the film opened their eyes and how I still don’t know what I’m talking about, because I’m not looking at this ~objectively or something.

It wasn’t all bad. It’s definitely a movie. And I agree with some points in the film, and there’s parts that I appreciate Canner including, like the part where we hear an anonymous woman talk about negative side effects she experienced after her genital surgery. (What, am I supposed to say it’s totally risk-free and problems never happen and la-de-dah? If anything I know full well complicatons can result.) I know sex education matters, I know an equitable division of labor matters in couples (though where that leaves the single ladies who just miss masturbating remains unclear to me,) I know Big Pharma is motivated by profits. I know most women never have to deal with this shit, I know drugs cost money and have side effects, etc. etc. etc., Reganomics. I am fully aware of all this. But a lot of people love this film unconditionally – so why I am I still seeing some flaws. Was it overrated? Yes, at least I thought so. It still wasn’t enough to convince me to go over to the other side.

Doctors debate dyspareunia part 4: The debate continues

09/19/2011 at 10:51 pm | Posted in Uncategorized | 3 Comments
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“The sad truth is that at our current state of knowledge, sexual dysfunction is whatever sexologists or others say it is” – Yitzchak M. Binik, Ph.D.

The above quote comes from the person responsible for setting off the 2005 sexology debate about how doctors should address dyspareunia (painful sex,) and it succinctly reflects my own frustration with the field of sexology.

Recently, I have directed reader attention to a debate that took place amongst doctors and other professionals tasked with treating sexual pain problems. The debate started when Dr. Yitzchak M. Binik wrote in to the peer-reviewed journal of the International Academy of Sex Research, Archives of Sexual Behavior, on whether dyspareunia should be viewed primarily as a pain problem or as a sex problem. To catch up with this blog’s review of the debate, read part 1 here, part 2 there, and part 3 last.

Dr. Binik’s original article outlined his position that sexual pain is best classified as a pain condition under the DSM-IV-TR criteria. Currently it remains classified as a sexual dysfunction, though the soon-to-be-released DSM-V will likely change the name and the definition.

Dr. Binik’s publication in the Archives received 20 responses, expressing varying levels of support. I did not read all 20 of the responses he received. In parts 2 and 3 of this blog’s dyspareunia-as-pain series, I zeroed in on Dr. Leonore Tiefer’s fascinating and contradictory response, because I’m already familiar with the rest of her work with regards to sexual dysfunction.

Dr. Binik reviewed each response to his original article, and finally addressed them in a sequel, Dyspareunia Looks Sexy on First But How Much Pain Will It Take for It to Score? A Reply to My Critics Concerning the DSM Classification of Dyspareunia as a Sexual Dysfunction. Now this is another article behind an academic firewall, so most readers can’t see the full text. In the interests of spreading knowledge about sexual dysfunction, I can only provide an executive summary.

The first thing that jumps out at me in reading Dr. Binik’s final answer is that, this article is almost intolerable.
Basically, Dr. Binik says that he was late in getting back to everyone who replied to his original article because he was distracted by baseball season. I find it ironic that, in light of the continuing debate among sexologists about the appropriate use of the term “Sex addiction,” here Dr. Binik flippantly refers to his interest as “my baseball addiction” (63.) My amusement eventually gave way to groans of annoyance with all the sports metaphors and puns strung throughout the rest of the article. Clearly, Dr. Binik still had baseball on the brain when he penned this reply. That in no way diminishes the validity of his arguments; it just annoyed me on a personal level.
Remember, there is already a baseball metaphor used in casual conversations about sex – “Bases.” Each base represents an arbitrary milestone in heterosexual sex, where running through all 4 bases means you’ve progressed to hetero, PIV intercourse.
Fortunately, the article is short – about 4 pages, as opposed to the original 10+, so I didn’t have to put up with the sports jargon for long.

Dr. Binik acknowledges that his original article met with mixed reviews from his colleagues & peers. For the most part, Dr. Binik’s assertion that sexual pain should be reclassified as a DSM-approved pain condition did not go over well. Three respondents endorsed Dr. Binik’s original position that sexual dysfunction should be reclassified as a DSM-approved pain problem. Five vehemently opposed the change. Nine responses agreed with part of what Dr. Binik said, but not everything. And three didn’t really address the question at all (63). You can find publication details about the 20 responses here. PubMed does not provide full text or abstracts for any of them, but I have GOOD NEWS, everyone! Today I found a compilation of all of the responses to Binik’s article on Ohio State University’s website! If you’ve got hours of free time, you can read and analyze each individual response, spanning some 40 pages! Except for the response we’re looking at today.

Dr. Binik interprets the disagreements as stemming from four basic positions:

(1) I overgeneralized from one typ eof dyspareunia – vulvar vestibulitis syndrome (VVS); (2) my reclassification strategy for dyspareunia was of dubious clinical utility; (3) I did not recognize that dyspareunia really is a sexual dysfunction; and (4) I confused symptom and mechanism in my discussion of classification (63).

Dr. Binik did not deny focusing exclusively on VVS, even though it is not the only type of pain one can experience during sexual activity (63). It is, however, the best researched type of sexual pain, and the research on it provided the most support to Dr. Binik’s position (64). He talks about how post-menopausal dryness & vaginal atrophy may be another sexual pain – except for the part where, due to lack of systemic research on the topic, he isn’t convinced that these problems can account for dyspareunia (64).

To the criticisms that reclassification (moving dyspareunia from sexual dysfunction to pain condition,) wouldn’t solve any problems, Binik responds that the outcome results couldn’t possibly worse than they are now. Some critics pointed out that both the sexual dysfunction and pain condition categories in the DSM-IV-TR both have problematic elements (64). What those problematic elements are, is not discussed in this particular article; we need to examine the primary source responses in question for supporting details. Dr. Binik, however, contends (perhaps somewhat blithely,) that if professionals fix the problems inherent with the DSM pain classification, then sexual pain would fit in with that category (64). And with regards to concerns that pain clinics may not be prepared to handle sexual complaints, Dr. Binik says,

Several commentators (e.g., Carpenter and Anderson, Strassberg) implied that the sexual concerns of women with dyspareunia might get ignored if they go to pain clinics. I think they underestimate clinicians/researchers, such as Masheb and Richman, who work at such multidisciplinary clincs and are very sensitive to sexual issues. It is no more difficult for professionals at a pain clinic to learn about sex than for sexologists to learn about pain (65, emphasis mine.)

In that case, my fellow folks with sexual pain, we are fucked! And not in the good, clean fun way; I mean, I am so completely frustrated with how poorly some notable sexologists handle sexual pain! If I have to look to sexologists as an example of how professional disciplines handle overlapping issues, then I am hopeless that pain professionals could possibly do any better with sex! I have seen sexologists and popular sex bloggers online who write about dyspareunia, and the extent of their writing is, “Refer to your doctor.” That’s it; that’s the extent of their learning, to this day in 2011. Since there are still sexologists who can’t be bothered to learn about the intricacies of sexual pain, I remain unimpressed. So given sexology’s poor track record of handling dyspareunia, why should I believe a pain doctor could do any better at handling sexual problems?

Facepalm Carl Pictures, Images and Photos

[Description: Carl - a heavy, hairy white guy from Aqua Teen Hunger Force - looking exasperated and doing a Facepalm. Wearing a white tank top and tacky gold chain.]

Moving on, other commentators maintained that sexual pain is and should continue to be recognized as a sexual dysfunction. This was Dr. Tiefer’s surprising, contradictory argument. However, when Dr. Binik explicitly addressed Dr. Tiefer’s response directly, he clearly missed her point.
See, Dr. Tiefer’s whole schtick is that sexual dysfunction is an artificial construct designed to benefit the medical industry, Big Pharma in particular. The New View Campaign’s social construction perspective dictates that most sexual problems stem from social problems and can be addressed through broad, non-medical interventions. But Dr. Binik clearly is not familiar with The New View or with Dr. Tiefer’s work, because he said,

For example, Tiefer argued that “dyspareunia is the only true sexual dysfunction,” because “…sexual problems [are best defined] as discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience.” (p. XX). While I have some sympathy for this definition, it is too broad since everything that intereferes with sex (e.g., watching too many baseball games?) becomes a sexual dysfunction (65).

Wait, what the f—?! Gaaah!!! That’s not what she said! She never said that! That’s the opposite of what Dr. Tiefer’s been saying for ten years!!! I cannot believe — I can’t deal with this shit! The right hand doesn’t know what the left is doing!

[Description: Captain Jean Luc-Picard, a bald white guy from Star Trek, doing the Facepalm.jpg thing. From Know Your Meme.]

One area where Dr. Binik and Dr. Tiefer agree, is that the current classification of sexual dysfunction in the DSM-IV-TR is so problematic that it probably needs to be scrapped entirely and done over – and this is, apparently, one of the reasons why Dr. Binik wants dyspareunia moved out in the first place (65).

The last main argument against Dr. Binik’s reclassification scheme is the one I’m having the most difficulty understanding. Some commentators questioned whether Dr. Binik was endorsing a classification scheme based on symptoms or one based on mechanisms (the underlying causes of pain, like inflammation.) Dr. Binik clarifies that he doesn’t like symptom-based classification schemes, but we’re pretty much stuck with that until researchers figure out what the mechanisms behind sexual pain actually are (66).

Dr. Binik then responded briefly to a few additional criticisms of his original article, like the fact that he left vaginismus out of the discussion (an oversight he didn’t want to make but felt obligated to do since vaginismus is treated differently in the DSM for some reason) (66). Binik actually retracts one of his arguments in favor of moving dyspareunia over from sex to pain. Initially, Binik suggested research funding as one of the reasons he supported making the switch, thinking that pain research is easier to fund since it’s less controversial than sex research. He was called out for this claim by Black and Grazziotin (66).

In the end, Dr. Binik was not convinced by the respondents that sexual pain is best left as a sexual dysfunction. He is glad to have started the conversation though, and it’s possible that this discussion did play a role in the changes to dyspareunia as described by the DSM-V. Unfortunately, Dr. Binik uses a baseball metaphor with a double-entendre to conclude his article with an expression of gratitude with participants in the conversation,

“It is clear that my article did not hit a home run; however, dyspareunia is looking sexy enough to have finally gotten to first base. I think it will finally score in the major leagues” (66.)

He means his article wasn’t met with the adulation and acceptance he was expecting. This is an awkward way to put it though, considering that dyspareunia, in my experience, is the opposite of sexy and here again all I can think of is the sexual double entendre of baseball metaphors. Either I have a dirty mind or else Dr. Binik overlooked the phrase and how it might interfere with a serious discussion of sexual pain.

So what did we learn from this debate? Here’s what I learned:

If there’s only one lesson I want readers to take home, it is encapsulated in the opening quote to this post. Getting professionals involved in sexual research and medicine to agree on a definition of sexual dysfunction is like trying to herd cats. (Not to mention the fact that many professionals have neglected to involve their own patients’ feedback in the discussion – hint, hint!) We have an arbitrary definition spelled out by the well-known APA’s DSM, but in practice it’s more of a guideline than a hard set of rules, and there’s much it overlooks.

Different professionals may not agree with the DSM classification of sexual dysfunction for various reasons, and will come up with independent working definitions instead. These fractured definitons will reflect whatever agenda the professional(s) who developed it wish to spread and capitalize on. Different agendas may make some good points and thus be defensible, even when in direct conflict with one another.

I’ve seen examples of these contradictions illustrated before; One Ph.D. says porn addiction is a real thing that must be stopped, while another Ph.D. says there’s no such thing as sexual addiction, only sexual impulses. If both start sexual counseling clinics that reflect their views, then whose therapy the most appropriate? So in the end, sexual dysfunction remains a white-hot conflagration of controversy and disagreement – Looking at it pragmatically, to rephrase Dr. Binik, sexual dysfunction is whatever anyone wants it to be. You want it to be pain only? Boom, done. Wait, this other person wants sexual dysfunction to include lack of sexual arousal? Bam, here’s a phone number for a clinic you can call for that. Wait, this other person says all sexual dysfunction isn’t real at all? Boosh, here’s a whole lesson plan you can integrate into your gender studies program supporting that position. Even if some professionals manage to come to a stalemate and agree with each other on certain points, on others there will inevitably be disagreement.

I suppose this is the way science is supposed to work. Doctors and researchers are supposed to go back and forth at each other in order to find the correct answers to life’s big questions. It’s all part of the process.

But sometimes when I see these contradictory perspectives of sexual dysfunction, I get so frustrated! Then all I can do is think of the sexologists involved as chasing each other around, re-enacting the Yakety Sax scene from Benny Hill. Then I feel better:

(I couldn’t find the original Benny Hill chase scene in YouTube. Deal with it.)
[Description: Black-and-white chase scenes from Charlie Chaplin silent film, "The Tramp," set to the fast-paced & wacky music, "Yakety Sax." Charlie and co. generally cause mischief and misery to a team of cops trying to catch him and another character. Features running into some kind of fun-house boat with a hall of mirrors; Charlie and another character pretending to be animatronics in order to hide in plain sight from police, messing up a spinney Coney Island-era ride inside of a circus setting and general mayhem.] 

One interesting part of this debate is how it contrasts with the history of sexual dysfunction as presented by Dr. Tiefer in the chapter, “‘Female Sexual Dysfunction': A New Disorder Invented for Women,” (quotations are hers not mine,) included in the anthology Sex is not a Natural Act. When she reported on sexual dysfunction conferences attended by medical professionals, she made it sound like a bunch of rich doctors all went in, bullshitted with each other, slept in the fanciest hotel suites, maybe bathed in goats milk and children’s tears, had a few drinks, and all agreed unanimously about a common definiton of FSD – a definition conveniently designed to line their own pockets. But instead, here, we’re seeing a much more lively & varied debate unfold.

Meanwhile, patients with sexual problems find varying levels of treatment and in some cases may be blocked from having sexual dysfunction treatments made available to them in the first place, whether that’s for safety reasons or purely political & idealogical ones. But its all in our best interests, right? …Right…?

On the other hand, I’m somewhat relieved that there isn’t a universal accord on sexual pain, precisely because that means there’s still a chance for patients to influence doctors along and get them to listen. But it’s a very slim chance – A notable omission in this debate is the involvement and perspective of patients. It’s possible that some participants in the debate themselves had experience with sexual pain, but judging from the credentials provided by the respondents, they were not answering as lay patients. These doctors talk to each other, but not to us; they talk about us, and that’s something disability advocates in particular have long recognized as a problem. Furthermore, the academic firewall helps reinforce doctors’ various levels of power over patients – I didn’t even know this debate happened until relatively recently. Then, I had difficulty researching it as someone no longer affiliated with an academic institution.

Other lessons include: Although sexual pain does not effect only women, it is still looked at as primarily a women’s issue. The most common reason I’ve seen cited for this is that sexual pain disproportionately impacts women. However, by focusing on women exclusively, professionals are probably hurting men and folks who do not fit onto a gender binary.

But as far as the original question goes: Should dyspareunia be classified as a pain or sex problem? Whether painful sex is best classified as a pain condition or as a sexual dysfunction, there is no final answer. Jury’s still out deliberating. Dr. Binik and commentators made good points defending their opinions, but no one budged from their original positions. There was no argument so logically perfect, it had the power to change minds.
Sorry gang, I don’t have an answer to this question.

Doctors debate dyspareunia part 3: Pain’s validity, con’t

08/24/2011 at 9:44 pm | Posted in Uncategorized | 2 Comments
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[We're picking up this post directly where the last one left off, because it was getting too long. If you're just joining us, we're in the middle of a conversation about whether doctors think painful sex is best looked at as a pain problem or as a sex problem. Read part 1 here, and part 2 there. Stay tuned for the thrilling conclusion!]

In her response to Dr. Binik’s original article, Dr. Tiefer then goes on to acknowledge that dyspareunia is a surprisingly common experience. Dr. Tiefer says that sexual pain is deeply important to the feminist community: 

Beyond womens’ lack of sexual satisfaction or lack of orgasms, the common experience of pain during intercourse or vaginal penetration lies at the heart of the feminist critique of patriarchal sexual relations (e.g., Boston Women’s Health Collective, 1998, pp. 256-257) (51.)

*record scratch sound*

The heart of feminist critique of patriarchal sexual relations?

think in her citation, Dr. Tiefer is referring to an old version of Our Bodies, Ourselves. That’s The-capital-T Feminist Health Text Book put out every few years by the Boston Women’s Health Collective. It comes in different flavors, like one version for menopause and another for pregnancy, so I’m not certain which OBOS she’s referring to.

But…

Let me put it to you this way: I don’t know what’s on those two pages cited by Dr. Tiefer, because I no longer have a copy of OBOS. During my major life upheaval, I left it behind because it didn’t have anywhere near enough information on sexual pain. I remember about one page on vulvodynia, and there was a little bit about FSD in general – citing Dr. Tiefer’s work, in fact.
I was so disappointed at seeing little about sexual pain relative to chapters about pregnancy, sexuality, abortion, and other human rights issues, that I dumped OBOS. The Boston Women’s Health Collective let me down. I turned to other books, not specifically feminist ones, for more comprehensive information.

I don’t think there’s much support to the claim that vaginal or sexual pain lies at the heart of feminist critiques of patriarchal sex. Perhaps it’s just that feminist perspectives of patriarchial sex are a tiny niche, and so small that I miss them when scanning with my naked eye. After all, I often see feminist critiques of sex and sexuality generally, or I see critiques of patriarchal sex and rape culture that do not explicitly address the existence of unwanted physical pain.

But feminist perspectives on painful sex specifically are hard to find. I seek essays about vaginismus & vulvodynia in feminist-oriented traditional printed media on purpose. I have only just barely scratched the surface of a large feminist library, but it’s still pretty rare for me to find much about dyspareunia.
Online, I recall Twisty Faster’s post about vaginismus from a few years ago as a feminist perspective on patriarchial sex and a painful sexual problem – and even then, her post was more about treatment than about the experience of vaginismus itself. Every once in awhile I’ll find posts about sexual and genital pain on popular feminist sites, and I am eternally grateful when I receive guest posts that address the subject here. But big social justice & feminist sites have to keep up with all the other social-justice news too, and the pain posts get buried after awhile.

So to say that pain with sex or vaginal insertion lies at the heart of feminist critique of patriarchal sex is an exaggeration at best and bullshit at worst. It’s not there, not at the heart. It’s off to the side, maybe; on a good day you can see it poking out. Then it sees its shadow and bolts for another few months before making another appearance.

Anyway, back to the article. Dr. Tiefer then talks about how feminist sexologists have emphasized downplaying the centrality of penis-in-vagina intercourse as the end-all, beat-all form of sex – Dr. Marty Klein wrote an entire book about this, in fact. And then there’s a mention that sexual pain is implicitly (but for some reason not explicitly) covered by the World Association of Sexology’s Declaration of Sexual Rights (51.) For the record, I think the declaration document linked to in Dr. Tiefer’s original response has been updated since 2005. The URL changed to something else sometime in the last few years and the phrase “Sexual pain” does in fact appear in the body of the text (once.)

Towards the end of her response, Dr. Tiefer states that dyspareunia falls under the New View’s definition of a “Sexual problem,” whereas Dr. Binik’s view is that there is no special type of pain that applies only to sexual situations. (For example, in Dr. Binik’s view, vulvar vestibulitis is a primarily a pain problem rather than a sex problem, because you get the same pain during sex as you get during a routine gynecological exam.) According to Dr. Tiefer, even if sexual dysfunction as we know it were to be redefined or dropped from the DSM classification system altogether, pain during sex would still remain primarily a sexual problem that can be looked at from a social construction perspective -

We recommend that professional nomenclature dispense with the idea of norms and deviance… and move to a model wherein sexuality was viewed as a cultural construct and individuals could have various subjective or performance problems. Thus, sexual pain would be like swimming pain or swimming phobia, a problem that a person had with a desired behavior, not with some universal capacity (51, emphasis mine.)

Wait, what? “Swimming pain?” “Swimming phobia?”

Ironically I think comparing sexual pain to swimming pain strengthens Dr. Binik’s argument in favor of reclassifying dyspareunia as a pain condition – is there a special type of pain that kicks in only when swimming? Seriously, I’m asking because I’m not a doctor and I don’t know.

Swimming pain a vague term – are we referring to the pain of a muscle cramp, a broken limb, skin irritation from an over chlorinated pool, or swimmer’s ear? Plus, swimming doesn’t carry around the same gender, consent and relationship issues that sex does. (We could make an argument that swimming does carry performance issues, I suppose, especially when done professionally or in athletic competitions – but even then, I don’t think I’ve ever seen swimming activity stigmatized the same way I’ve seen sexual activity get turned into a problem in and of itself.)

I find the comparison of sexual pain to swimming phobia to be the more problematic half of Dr. Tiefer’s statement. I’ve come a long way from the time when I had a lot of fears and anxiety about sex. Somewhere along the line while puzzling sex out (and maybe while blogging about it,) some of the old fears started to slough & flake off. And at this point, It is no longer the act of sex that I fear. It’s the pain that I have come to expect if I try to engage in sex. So some folks who have experienced painful sex do have, or go on to develop, fear of sexual activity in and of itself. But now, years later, I’m still dealing with dyspareunia over here, not erotophobia or genophobia. I’m concerned that conflating sexual pain with sexual phobia will only complicate getting pain patients the comprehensive treatments they need the most.

Dr. Tiefer’s choice of words here was probably deliberate. This isn’t the first time she has compared avoiding sex and avoiding swimming:

Who’s to say, for example, that absence of interest in sex is abnormal according to the clinical definition? What sickness befalls the person who avoids sex? What disability? Clearly, such a person misses a life experience that some people value very highly and most value at least somewhat, but is avoiding sex “unhealthy” in the same way that avoiding protein is? Avoiding sex seems more akin to avoiding travel or avoiding swimming or avoiding invsetments in anything riskier than savings accounts – it’s not trendy, but it’s not sick, is it? (Sex is not a Natural Act, location 243).

Yet if a patient avoids sex due to dyspareunia, in that case it seems to be acceptable to view the avoidance as part of the sexual dysfunction that is painful sex. This is all very contradictory and confusing to me.

Dr. Tiefer ends her response to Dr. Binik by summarizing her position on the reclassification of dyspareunia: “As long as there are expert-based listings of sexual dysfunctions, we do women a disservice by failing to include pain as one of them,” but ideally she’d prefer to see classifications based on arbitrary norms dropped altogether (51.)

And that’s the way Dr. Tiefer’s response to Dr. Binik ends.

I find it disturbing that in spite of the New View’s probing explorations about how sexual dysfunction is arbitrarily defined in the DSM, in this response Dr. Tiefer felt it appropriate to make an artibrary decision about how to look at dyspareunia. Whereas in the past she has questioned whether or not disorders of desire and orgasm are truly a form of illness or disability, here, she made the unequivocal decision that sexual pain is in fact a sexual dysfunction.

I don’t know what to make of this contrast between Dr. Tiefer’s previous work and this article. Low sexual desire is not a disease… but feeling sexual pain is.
You are not sick if you can’t have an orgasm… but if your crotch hurts, then of course there’s something wrong with you. It’s normal and acceptable to go through periods of low sexual interest, especially if you’re tired… but if sex hurts, then that is not normal.

On the one hand, it makes some sense to me. Statistically, most people do not experience sexual pain – at least, not chronically, and not without some reason. In terms of raw numbers, it certainly is unusual to feel pain with most or every sexual encounter. And for me, personally, after careful consideration I view the pain I have as a sexual dysfunction.

But on the other hand, here I see a one-sided judgement about how normal my experience is, and by extension, how normal I may or may not be. If dyspareunia is recognized as a sexual dysfunction, then that’s an abnormality, isn’t it? So then, am I abnormal too? If so, what exactly am I supposed to do about it? Do I even have to do anything? What does it mean to have a feminist organization ask questions like, “Where are the women” in discussions of sexual dysfunction – and then have one leader of the organization declare what’s going on with women who have a certain type of sexual problem, without their feedback first? Where are the women, indeed – where are the women with sexual dysfunction when the doctors debate back and forth with each other?

When do the women with sexual dysfunction get a say? Dr. Tiefer does not speak for me; and I represent no one but myself.

By focusing on language, there are several dyspareunia issues Dr. Tiefer didn’t address. Practical questions like, if dyspareunia remains a sexual dysfunction, what treatments are appropriate to address it? Given the her criticism of the role of Big Pharma in marketing brand-name medications for other sexual problems, is it acceptable to offer oral pain medication as a treatment for this sexual problem? Or are pain medications and devices for sexual problems to be viewed as yet another tendril of dangerous, Big Bad Pharma? Is it appropriate to look at sexual pain as a relationship problem that exists only when trying to engage in partnered sexual activity, or is it a health problem in and of itself that exists independently of relationship status?

And it’s still not entirely clear to me which class of doctor Dr. Tiefer feels is best suited to handle complaints of sexual pain – If sexual pain is in the DSM, which various health professionals use, then does that make sexual pain a medical problem? Who should address it, medical doctors? Sexologists? Psychologists?

I don’t have the answers to these questions. I’m interested in the answers though, because in the end, I am someone directly effected by the decision makers. Ultimately it’s my health at stake in this debate. The decision of who is best equipped to address sexual pain will impact who I must seek out for assistance, what kind of help I can expect to receive, and how soon I can expect to see results, and how satisfactory results will be measured. It’s not an understatement to say that my future lies in their hands.

The debate about sexual pain didn’t end with Dr. Tiefer’s response, nor did it end with the other 20 or so articles generated by Dr. Binik’s 2005 discussion. Eventually Dr. Binik wrote up a conclusion in which he acknowledged & evaluated each reply. But an evaluation of his final answer on what to do about dyspareunia will have to wait until next time.

Doctors debate dyspareunia part 2: Is pain the only valid FSD?

08/17/2011 at 9:51 am | Posted in Uncategorized | 3 Comments
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Previously on Feminists with Female Sexual Dysfunction…

Many folks who experience sexual and/or genital pain share the experience of getting bounced around from doctor to doctor when seeking satisfactory resolution to their problems. In a recent post on this blog, I explored one of the many reasons the doctor shuffle occurs: there’s no definitive class of doctor designated to handle sexual & genital pain. And behind the scenes, doctors themselves are debating what medical specialty is best prepared to address this type of problem.

In 2005, a peer-reviewed journal published an article by Dr. Yitzchak M. Binik, Ph.D. His idea was to start a serious debate on how best to handle dyspareunia (painful sex.) Currently, under the DSM-IV, dyspareunia is classified as a sexual dysfunction. When the DSM-V revision comes out, it is likely to be kept there (though under a different name, genito-pelvic pain/penetration disorder.)

Dr. Binik made some compelling arguments in favor of of changing the classification of sexual and genital pain from a DSM-recognized sexual dysfunction to a pain disorder. But his position was controversial, and generated many professional responses against making the switch.

One such published response came from Dr. Leonore Tiefer, a feminist sexologist, author, college professor and organizer behind the New View Campaign, an organization opposed to the medicalization of sex, with a particular focus on the role of Big Pharma. I have read and reviewed some of Dr. Tiefer’s previous work on this blog, bringing to it my own unique perspective as someone who actually has FSD.

Unfortunately this time I won’t be able share the full ~2 page text of Dr. Tiefer’s response, Dyspareunia is the only valid sexual dysfunction and certainly the only important one, because it’s locked down behind an academic firewall. I think I can share a summary of what’s in it (with my own commentary,) but unless you’re enrolled at a school with journal access, you’ll have to take my word on good faith.

Dr. Tiefer’s disagreement with Binik’s reclassification argument focused exclusively on one argument: Nomenclature; the power of names. It’s a familiar theme in Tiefer’s earlier work – language is a powerful tool capable not only of reflecting reality, but of shaping it. And Dr. Tiefer has serious concerns about the language used to describe sexual problems in particular. In light of this, I was surprised to find that in her response to Dr. Binik’s article, Dr. Tiefer argued in favor of keeping dyspareunia classified as a sexual dysfunction instead of a treating it as a pain problem – At least, so long as such terminology is used by the American Psychiatric Association.

Dr. Tiefer starts her article by describing the origins and goals of the New View Campaign. One of Tiefer’s criticisms of female sexual dysfunction is that it’s based on the idea of deviations from a “Normal,” universal sexuality, but normal is arbitrarily defined and doesn’t account for all of the human population. In this case, the “Normal” sexual response cycle was defined by Masters & Johnsons’ work – the four-phase model that goes, excitement, arousal, orgasm and resolution. Sex doesn’t work that way for everyone, and so over the last few years – decades at this point – she has challenged the medicalization of sex, with a particular interest in libido and orgasm.

“My criticisms have, however, focused on the universalized notions of desire, arousal and orgasm in dysfunction nomenclature, and not on the inclusion of dyspareunia and sexual pain. Immersed in the feminist literature on women’s health, I was more than aware of the disgraceful history of neglect and mishandling of women’s complaints of pelvic pain and thus it seemed that dyspareunia was the only sexual dysfunction with validity in women’s lives (50, emphasis mine.)

(And that’s where the title of the article comes from. I don’t know whether Dr. Tiefer picked the name out herself, or if some editor arbitrarily decided it, but we have the same sentiment reflected in the body of the text.)

However, when criticizing female sexual dysfunction, Dr. Tiefer has in the past included pain. It’s true that she doesn’t talk about it much, relative to her body of work on orgasm and desire. But in the past she has let pain stay under the broad umbrella of the term, “Sexual dysfunction,” complete with scare quotes:

We believe that a fundamental barrier to understanding women’s sexuality is the medical classification scheme in current use, developed by the American Psychiatric Association (APA) for its Diagnostic and Statistical Manual of Disorders (DSM) in 1980, and revised in 1987 and 1994. It divides (both men’s and) women’s sexual problems into four categories of sexual “dysfunction”: sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. These “dysfunctions” are disturbances in an assumed universal physiological sexual response pattern (“normal function”) originally described by Masters and Johnson in the 1960s.

In the New View manifesto, Dr. Tiefer kept sexual pain disorders lumped with all the other dysfunctions that merit feminist skepticism and critique. Feminist critique, such as the perspective that DSM criteria for dysfunctions (including pain) are excessively genitally, and therefore reproductively, focused (Sex is not a Natural Act, location 737.) However in 2005 we see support for leaving dyspareunia behind, as the only valid sexual dysfunction.

Dr. Tiefer’s quote about the importance of dyspareunia as dysfunction is problematic for additional reasons: The implication here is that no other sexual dysfunctions recognized in the DSM have any merit as a health problem. That’s a key point of the New View Campaign: Desire, arousal, and orgasm problems may not be problems at all, and when they are, the problems can be addressed with lifestyle and social change instead of medicine. But here I interpret the idea that pain is a sexual dysfunction, and the only valid one, as maintaining a sexual dysfunction hierarchy. It elevates physical pain above all others. My problem matters; yours doesn’t. My physical pain is real, your emotional or psychological pain isn’t.

So what does this mean for folks who have one of the less-important, invalid dysfunctions? To whom can they turn when they have exhausted virtually all of the non-medical interventions for long-term sex problems?

Dr. Tiefer then briefly expands on some implications of Masters and Johnson’s work. In the next section of her response, she describes an alternate, benevolent way of looking at the inclusion of sexual dysfunction in the DSM: Recognizingsexual problems as health and medical problems legitimizes such problems in the public’s eye. Suddenly, sexual problems are no longer just about sex, which (according to vocal conservatives anyway) is dirty and wrong and immoral – sexual problems are now about the body and health, which is (relatively) socially and politically acceptable to talk about. “Looked at from this perspective, the inclusion of women’s problems with sexual pain in the sexual dysfunction classification system was a positive step” (50,) because then the ISSVD and NVA can harness that legitimacy for raising awareness and research funding.

It strikes me as odd that Dr. Tiefer mentions the NVA and ISSVD by name as working for the benefit of patients with pelvic pain problems. Not because I have any question that both organizations do good for the public, but because in Sex is not a Natural Act, Dr. Tiefer had this to say about patient advocacy organizations:

These advocates for medicalization include self-help group and newsletter promoters who have created a market by portraying themselves as something between consumers and professionals. The formation of Impotents Anonymous (IA), which is both a urologists’ advocacy group and a self-help group, was announced in the New York Times in an article including cost and availability information on penile implants. (Organization helps couples with impotence as problem 1984.) … The advocates for medicalization portray sexuality in a rational, technical, mechanical, cheerful way. Sexuality as an area for the imagination, for political struggle, or for the expression of diverse human motives or as a sensual, intimate, or spiritual rather than performative experience is absent (locations 2277-2282.)

Basically, according to Dr. Tiefer, patient advocacy groups – at least those for erectile dysfunction – existed partly in order to sell sexual health problems, to promote a select few doctors qualified to treat the problems, and then to sell medical treatments for big bucks. In these earlier statements, Dr. Tiefer made it sound like patient advocacy groups were just part of the packaging that came with so-called selling sexual dysfunction. In fact, the formation of patient advocacy groups is one piece of what motivated Dr. Tiefer to organize the New View Campaign in the first place:

This backlash dovetails with the analysis and critique of “medicalization” over the past several decades within sociology, the women’s health movement, the “anti-psychiatry” movement, and newly, from cultural historians examining the social construction of illness and disease. All these scholars argue that the medical model, with its hallmark elements of mind-body dualism, universalism, individualism, and biological reduction, is not well suited to many of the challenges of contemporary life and suffering.

Yet, at the same time, patient advocacy groups are clamoring for medical legitimacy, increased funding and research, and, above all, new drug treatments. And the drug industry continues to expand.

Allying with the backlash, I convened a “Campaign for a new view fo women’s sexual problems” in 2000 to provide a feminist anti-medicalization perspective in the debate about “female sexual dysfunction” (location 3550.)

Given these prior statements on patient advoacy groups, I’m surprised that Dr. Tiefer didn’t skewer genital & sexual pelvic pain advocacy groups in her 2005 response to Dr. Binik.

Furthermore, by classifying dyspareunia as a sexual dysfunction, isn’t dyspareunia and its treatment subject to the same criticisms that Dr. Tiefer has previously made about sexual dysfunction and Big Pharma broadly? I’ve seen the rhetoric used by the New View used (and unfortunately warped) in feminist arguments against sexual medicine. And let me show you, it can get real ugly real fast. Leaving sexual pain as a sexual dysfunction might lend medical and social legitimacy, but not when you do everything you can to undermine the legitimacy of sexual dysfunction broadly and stigmatize those who experience it.

This post is getting way too long, so we’re going to stop abruptly here and come back after you’ve had a few days to digest our story so far. To be continued…

Shorties II

03/21/2011 at 2:10 pm | Posted in Uncategorized | 4 Comments
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In the same spirit as the original Shorties, I bring you: A series of posts which were each too small to constitute blog entries on their own. Divided we are weak, but together, we are strong!

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The National Vulvodynia Association’s newsletter for 2010 is posted on their website, here. It includes updates on research and funding, and profiles of researchers who have received NVA-related grants. There are also profiles of medical professionals working towards a more comprehensive understanding of vulvodynia. There’s also updates on educational materials and programs provided by the NVA.

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There’s a couple of reasons I like to post book reviews on this blog. I may post product (vibrator, dilator etc.) reviews in the future; I haven’t decided yet. Again, a reminder: Any reviews I posted here so far, I had to pay for the product in question & I haven’t gotten any compensation for my services.

It’s a blog about sexual dysfunction, especially that greatest bone of consternation, female sexual dysfunction. One of the common themes I read in feminist analysis of FSD is that a lot of it is actually sexual insecurity which stems from ignorance and lack of education. The idea goes something like, men & women are socialized differently and grow up with different expectations & pressures when it comes to sexual behavior. (In other words, differences in sexual behavior between men & women aren’t necessarily inborn.) Women are discouraged from learning about sex & pleasure. Combine this with shitty sex education and you have a pretty good chance of not understanding the influence of gender roles and how your own body works. This in turn is misinterpreted by the individual as “There must be something wrong with me” when experiencing a normal, understandable reaction to sexual stimulation. And the cure for this is better sex education instead of medication. Go read a goddamn book or something!

Improved sex education is great, so that’s one reason to post reviews of sexual guides and products. So every one in awhile you’ll find such a review here – it’s my way of saying, “Hey, here’s something that’s good and worth your time,” or, “Hey, here’s an overrated product that isn’t worth the packaging it came in. Save your money.” Or I’ll post something more nuanced –  “This is good, this is bad, and this part I don’t understand at all.”

However there’s another reason I post the reviews here…
Sometimes all the sex education in the world cannot fix a sexual problem.
Because it doesn’t all come from sexual ignorance.
Many of the sexual guides I’ve read, some of which come highly recommended, do not do a good job of addressing my problem in particular – pain. Maybe it’s because they’re not medical advice books so they can’t recommend treatments. Liability issues, maybe.

I’m doing what I’ve been told to do. I’m getting better sex education. I read the blogs. I buy the sex toys from the feminist sex shops. I have explored my sexual fantasies and will continue to do so. I masturbate to orgasm. I am in love with a supportive partner (the feeling, I understand, is mutual.)

The lady with sexual dysfunction is reading a goddamn book or something.

So why do I still experience dyspareunia?
Why do I still have vaginismus?
Why does my vagina still take so long to recover from vaginitis?
Why is medical intervention the treatment that best addressed the sexual and chronic pain?

Hey wait a second, this isn’t working. I still want to have some penis-in-vagina sex over here and that’s still like, really hard to do. Maybe I’m just not reading books and trying to learn hard enough.

The sex education helps – it’s definitely worth something. But it’s not comprehensive enough for me.

Now we could say here that I am the special snowflake exception to the general rule that FSD is a fake invention designed by Big Pharma and evil doctors; Dr. Leonore Tiefer, organizer of the New View Campaign, said as much when she wrote, “Dyspareunia is the only valid sexual dysfunction and certainly the only important one,” in response to the suggestion that dyspareunia might be better considered a pain condition rather than a sexual problem.

So hypothetically I suppose I could say, “Fuck you all; I got mine.”

Hypothetically. I have no desire to actually do that and in fact I feel dirty for having spelled such a phrase out in text. Excuse me while I swish some mouthwash and/or wash my hands. Is that what I’m supposed to say? Is that the way I’m supposed to feel? Is this the signal that, as someone with dyspareunia, I’m supposed to shut my pie hole when I see folks with other dysfunctions belittled for it?
I maintain that elevating one or some forms of sexual dysfunction as more real than others creates and crystalizes an artificial hierarchy. And it throws folks with sexual dysfunctions other than or in addition to pain under the bus.

And if, for me, all the sex education in the world fell short of actual medical help from professionals, then why should I believe that it would be any different for all of my friends who have sexual dysfunctions that are not painful?
Not that sex education has been completely useless; far from it. I have taken advantage of the information I found useful. (I also tripped over the parts that were counter-productive.) But to deny medical options to women with sexual dysfunction is to remove an important potential treatment, which for some folks may very well be necessary to find sexual satisfaction. And I find it highly disturbing when such options are removed through means of threats & intimidation, shaming, or ableist comments.

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Speaking of dyspaerunia being “The only valid sexual dysfunction and certainly the only important one,” I made this Privelege Denying Dudette meme just for you:

[Picture: Background: 6 piece pie style color split with pink and blue alternating. Foreground: White girl wearing a green t-shirt, featuring an African-American Sesame Street muppet with nine different hairstyles, subtitled, “I Love My Hair.” Has a smug, arrogant facial expression and plays with her long, brown hair. Top text: “ [SEXUAL DYSFUNCTION ISN'T REAL, YOU DON'T NEED MEDICAL INTERVENTION IN YOUR SEX LIFE] ” Bottom text: “ [WAIT, YOU HAVE DYSPAREUNIA? YOU BETTER GO SEE A DOCTOR.] ”]

What? Wait, what’s it going to be, do I trust my doctors or not? Do they know enough about sex to help me or is it an exercise in futilty to even bring up a sex problem? Am I allowed to go to one of the heavily-marketed sexual dysfunction clinics Dr. Tiefer mentioned in Sex is Not a Natural Act when my regular gynecologist gets stumped and refers me to such a clinic? If I take a prescription for sexual pain, am I just feeding the Big Bad Phama Beast and looking for an easy, quick fix? If I get treatment for dyspareunia, does that count as medicalizing sexuality?

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I recently came to a revolutinary conclusion. If your definition of sex positive does not include sexual dysfunction, then your definition isn’t positive enough.

I want to go out of my way to explicitly include sexual dysfunction in sex-positive discussions. Because ignoring it, outright denying its existence, or claiming that looking at sexual dysfunction = focusing on the negative, will not make it go away. Insisting that sexual dysfunction is a lie erases people who actually have sexual dysfunction. As a result, people with sexual dysfunction are excluded from sex-positivity – and I hate that. There is push-back against excluding people with a history of STIs from the sex-positive community by means of negative, stigmatizing language – why not push back for people with dysfunction?

You know what? I have sexual dysfunction. I exist. This is a long- term thing for me that I do not foresee changing any time soon. It will not go away just because you are uncomfortable with dysfunction (and, by extension, disability. These two phobias tend to go tovether, possibly because dysfunction may be viewed as a sub-type of disability.)

Yet even with the dysfunction, somehow, in spite of everything, I am sex-positive. I have made peace with it – or, at the very least, I have made a truce with myself until I can figure something better out.

Insisting that sexual dysfunction isn’t real or that medical options are unwarranted is just going to make it harder to get the care that I and my friends need. It’s true that most people will never experience sexual dysfunction, and so will not require medical options to address it. Nonetheless, inevitably, some people are going to develop sexual dysfunction. Isn’t there a way we can focus on getting support to such folk, instead of trying to sweep ‘em under the rug?

Sexual dysfunction and sex-positivity do not need to be mutually exclusive.

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Sometimes, I worry a little bit about my reliance on a vibrator for orgasm. I think that, with enough practice, I probably could masturbate to orgasm using only my (or my partner’s) hands. But until then, I orgasm easily enough with a battery-powered vibrator.

I’m not worried about spending money on vibrators and thus supporting a capitalist system. I’m not worried about using my vibrators during sexual activity with my partner. I’m not worried that he’ll feel inadequate compared to my vibrator. I’m not worried about becoming addicted to masturbation. I’m not worried that I’m supporting the tyranny of orgasm.

The real reason I sometimes worry about using my vibrator is…
…I have this paranoid fear that some day space aliens or a freak accident or a Hollywood movie-esque disaster will unleash an electromagnetic pulse over the USA (home) and all elecronics will lose functionality.
Including my vibrators.
And then I’ll have to find a techno wizard to SteamPunk some kind of hand-cranked or steam-powered vibe for me. Possbily incorporating or inspired by one of the old-time antiques like those found in the Museum of Sex. And it’s just going to be really awkward and frustrating and I’ll probably have a lot of other important things to worry about post-EMP.

Obviously I don’t really know how EMPs work and I don’t really care. Everything I learned about them, I learned from movies.

I think about this with about the same frequency that I think about the Zombie Apocalypse as a real thing. Which is to say, not very often except for maybe after watching a movie about a zombie apocalypse or a post-apocalyptic setting.

Book review: A New View of Women’s Sexual Problems

11/16/2010 at 10:14 pm | Posted in Uncategorized | 5 Comments
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Several months ago, over the course of a five-part series, I reviewed sexologist and feminist activist Dr. Leonore Tiefer’s nonfiction anthology, Sex is Not a Natural Act and Other Essays. It presents her critique of contemporary discussions of sex, sexuality and sexual dysfunction, from a social construction perspective. (Basically that means that Dr. Tiefer gives significantly more weight to cultural influences on the formation and expression of sexuality than to biology.) While reading it was certainly an informative experience for me, it was also rough – at several points I tripped over apparent contradictions between what Dr. Tiefer had written in one chapter vs. another and multiple instances of disablist language. Overall, while I learned a lot about social construction and criticism of female sexual dysfunction as a diagnosis, the book left me feeling isolated and unsatisfied since biology and the availability of medical options have a strong impact on how I have sex.

So for awhile I and guest posters wrote about other stuff in the wide world of female sexual dysfunction. And then I had to take a hiatus from blogging so I could deal with real-life chaos. After settling into a new routine, I felt motivated to read something… Now seems as good a time as any to pick up A New View of Women’s Sexual Problems, another nonfiction essay collection detailing an alternate model for looking at women’s sexuality and dysfunctions. A New View doubles as an in-depth manifesto for the New View Campaign, complete with examples of how the New View model can be applied to real-world women’s sexual complaints. Let’s see what it’s all about.

Overall Impressions:

A New View is and feels significantly shorter than Sex is Not a Natural Act – it’s about 218 single-spaced pages, divided into three parts. Each chapter is short, ranging from just a few bite-sized pages up to around thirty, so it’s easy to digest. Each chapter was published simultaneously in the journal Women in Therapy, volume 24, issues 1 & 2, so you’re actually reading academic journal articles. Except for a few essays towards the end of the book, most of the time it’s generally not heavy on academic jargon.
Downsides unrelated to the writing: A New View is not available in e-book format and at about $30 on Amazon (new) it’s a little outside my sweet spot price range for something sans illustrations. I went in to the book hoping for a list that would explicitly spell out which biological problems get the green light for medical treatment but I’m still not clear on exactly when sexual medicine is appropriate (and why.)

On paper, the New View looks good. Overall, the book is nuanced and presents the perspectives of many professional women familiar with sexology, sexuality, women’s studies, feminism, psychology, health, and related fields. The responses to the New View manifesto illustrate its merits and practical application…
On paper.

In practice, I’m still wary of the manifesto and the eponymous organization. Reading the entire body of work has not sufficiently addressed my apprehensions.
Because in practice, I’ve seen the New View’s positions and activities turn into another prescriptive theory, one that creates new complications and restrictions for women even as it attempts to free them. For example, in practice, the strong emphasis on relationship problems can also oversimplify women’s sexual problems and turn into partner blaming. The New View’s insistence on referring to “Female/Pink Viagra” further obfuscates understanding the difference between arousal and desire, even when drugs like flibanserin do not work like Viagra. I was horrified to see New View organized petition to stop FDA approval of flibanserin, since I felt like the petition organizers overlooked whatever small number of women might actually benefit from such a drug, questionable though it is. Anti-Big Pharma arguments can easily turn into anti-medicine rants and rampant disablism. Looking for the deeper meaning behind sexual problems can turn into so much ‘splainin and Freudian analysis. And I think that by questioning the very existence of such a thing as female sexual dysfunction, the New View contributes to the further stigmatization of FSD. Basically, when used irresponsibly, the New View lends itself to Bingo Board fodder.

But on paper, the ideas are great. There’s even wiggle room for medical problems and biological factors as causes of women’s sexual problems (though the contributors are less interested in examining biological and health problems.)

In practice, the New View raises new questions and creates potential problems that warrant further examination.

Reading between the lines, you may notice some elements missing…

The New View Manifesto which guides the campaign was written from the perspective of professional women – psychologists, anthropologists, sexologists and related fields; however none of the original twelve named contributors to the succinct document had qualifications in medicine. There were no physicians, gynecologists or obstetricians involved in drafting the original manifesto. However, the document has subsequently received endorsement from several medical doctors and many therapists.
None of the contributors to the New View book disclose whether or not they have personal experience dealing with sexual dysfunction. The only clue we have as to whether an author with sexual dysfunction was included in this anthology may be found in Gina Ogden’s essay, which said, “I have been able to relieve much personal relationship angst by understanding sexual dysfunction as a manifestation of cultural dysfunction” (19). So there’s an “I” statement that touches upon sexual dysfunction and Ogden probably meets the New View’s definition of having had “Sexual problems,” but it’s not clear to me whether she ever considered herself to have a dysfunction. However even this statement ultimately rejects sexual dysfunction as an actual bodily phenomenon that women experience in and of itself. The rest of the book is likewise resistant to the very idea of sexual dysfunction as a valid medical problem.

There’s an expression in business, “Management sets the tone,” which means upper management, through actions and words, dictate the general atmosphere of an organization. It was Dr. Tiefer who pushed for the New View Campaign to come together, and throughout Dr. Tiefer’s essay, she consistently keeps the words female sexual dysfunction in “Scare quotes.” A footnote details the reason why: “4. I will put “FSD” (female sexual dysfunction) in quotations in this paper to indicate its questionable legitimacy” (92). Based on this, it seems highly unlikely to me that the contributors to this book would have actively reached out for feedback directly from women with sexual dysfunction. After all, if a condition is not legitimate and real, then who has it? There isn’t anyone with it to recruit.
Women who definitely had relationship and sexual problems and/or dysfunctions are presented as case studies in support of the New View model. Sometimes these women are quoted briefly, other times a contributor presents a summary of what brought a client in. Our words are presented through the filter of professionalism.
The omission of responses by women with sexual dysfunctions is a problem since such women are critical stakeholders in the New View model of sexuality and sexual problems. The New View is meant to be applied to women who experience sexual obstacles. But did anybody run the New View by the women who it most deeply effects before going to print? Based on one of Dr. Tiefer’s essays, it looks like the answer is No – the New View was drafted by about a dozen North American professional women based on their interactions with clients and with feminism (87); women with sexual dysfunction were not explicitly solicited for feedback. This is especially ironic in light of Peggy J. Kleinplatz’s essay, On the Outside Looking In: In Search of Women’s Sexual Experience in which she says, “Women’s sexual experience is conspicuously lacking from popular and sexological discourses of female sexuality” (124) and,

“Alternative models of female sexuality are called for which embrace the entire range of female sexuality from the vantage point of lived experience… A new epistemological stance is required which features women’s subjectivity at the center of inquiry. Female sexuality is best understood by listening to women’s own voices rather than attempting to peer from a safe distance and have our views filtered through the distorting lenses of conventional and sexological images of sexuality and female sexuality” (130).

Without follow through, calling out for the voices of women is little more than lip service. Nothing about us without us. (This is a continuing problem in the wide world of feminist writing, and writing in general.)
On the other hand, even if women with sexual dysfunction had been consulted when the New View document was first drafted ten years ago, I doubt it would have raised many objections or concerns. It looks fine on paper; it’s when and how you use the document to guide your activism that problems become are either solved or manifest.

I was surprised to see some criticism of the New View contained within the book’s pages: according to Gina Ogden, it may not have much to offer women who are extroverted in their sexuality. Jaclyn Friedman comes to mind, because Ogden says such women are labeled “Sluts” (19) and Friedman self-identifies as a slut, in the best way possible. So what does the New View, which focuses on negative sexual outcomes, have to offer her if she experiences sexual dissatisfaction? Good question.

The New View does a better job looking at causes for sexual problems than it does at offering guidance for what anyone should to do about it. I suppose that’s true of the DSM too though. One thing that’s clear in the New View is that medicine should generally be avoided, since medicine won’t address social forces, and it has been hijacked by for-profit entities.

And unfortunately the book doesn’t say anything about the grieving process you may go through (I went through it…) when it turns out that your sex life is not, and may never be, anything like what you had expected.

The book itself:

The first part of the book is the shortest – it’s the New View Manifesto document itself, which you can find online if you know where to look. It has been re-published on the Our Bodies, Our Selves blog supplement. (A later chapter goes into more detail about Dr. Tiefer’s connection with the Boston Women’s Health Book Collective, which I was curious about.) The document itself, not so bad. It does not use the label “Sexual dysfunction,” instead using the term “Sexual problem,” which is defined as, “discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience, may arise in one or more of the following interrelated aspects of women’s sexual lives,” and then there’s the whole bulleted point list of stuff that makes sex hard for women to enjoy. This alternative definition is similar to the DSM’s criteria of “Personal distress” in sexual dysfunction since it acknowledges the importance of personal dissatisfaction, but it’s more flexible in acknowledging what causes dissatisfaction, and the language is supposed to be less hurtful. It’s meant to acknowledge social influences and reassure women that there’s nothing wrong with them if they experience sexual problems. To the best of my knowledge the document has remained unchanged since the final draft was put together in 2000 (88).

The second part of the book consists of 10 contemporary responses to the New View. Professionals read it and wrote in about how it could be applied to their practices and/or demonstrating ways in which women’s sexuality is shaped by local culture – often with negative outcomes for the women, since culture is frequently patriarchal. Throughout this section, there is a strong emphasis on relationship factors as being the main culprit for women’s sexual problems. So what about all the single ladies who are not in a romantic/sexual relationship? Well, you still got a relationship with your friends right? Or your parental figures, or if you’re reading this blog then surely you have some kind of relationship with the media. Relationships! You can’t get away from ‘em.

The essays have merits, yes. But there’s flaws too. Here’s some examples of what I mean…

In the first essay response to the New View model, Dr. Lucy M. Candib presents a case study of a patient with sexual problems and lists elements of her problems that fall under all four of the main areas of the New View classification. It’s a compelling case. Yay! But then Dr. Candib says,

Practitioners may attempt to address the anger that women hold about both the division of labor and the experiences of abuse, but such anger is usually chronic, and many women develop symptoms in relation to it – headaches, chronic pain, fatigue, or depression – especailly when the relationship appears to be an inescapable trap (13).

Emphasis mine…Wait, what am I looking at here? I don’t think I like where this is going… didn’t DW user beautyofgrey talk about looking at “Unresolved anger” as a way to explain away what was actually a chronic, invisible illness? And didn’t she talk about how people interfere with her treatment decisions out of fear of Big Pharma?

Beth A. Firestein’s essay, Beyond STD Prevention: Implications of the New View of Women’s Sexual Problems talks about how a strong focus on sexually transmitted infection prevention fails to address the concerns of people who have or have had a STI. Prevention is great, but what happens if it isn’t enough? What happens when prevention fails and you catch a sexually transmitted infection? This chapter explicitly mentions the role of STI (or the fear of them) s in developing vaginismus, and this is the only chapter that explicitly mentions vulvodynia. Yay! However, this is the context:

3. Women who have partners that suffer from recurring outbreaks of a viral STD, such as veneral warts and herpes, or neurological pain disorders, such as vulvodynia, that cause pain with sexual activity or penetration, need to be helped to seperate fear from fact and to determine a personal range of safe and pleasurable sexual behaviors – behaviors that allow for sexual satisfaction of both partners while decreasing the risk of exposure to their partner’s disease. Such women could also benefit from coaching in ways to deal with a partner’s STD that protects the woman without eroding their partner’s sexual self-esteem or healthy sense of sexual self-expression (30).

I’m actually not put off about talking about vulvodynia in the same chapter as STIs, because Firestein’s view is meant to go beyond STIs and take away some of the stigma associated with them. This paragraph is somewhat awkward though, since vulvodynia is not actually an STI and it is not contagious, my partner does not need to worry about being exposed to it. A simple grammar tweak would likely strengthen this passage. I’m more concerned that this passage does not provide guidance with what to do if you are someone who has a chronic condition or infection… and you still want to go beyond your current safe range of activities. I already know facts about vulvodynia, probably more than the average sex therapist or general practitioner. My fear does not come from ignorance about my own health. Some women with vulvodynia still want to, or do, have sex even if it is painful, and this paragraph does not address what steps might be taken in those situations.

Dr. Lisa Aronson Fontes’ essay on Latina sexuality, The New View and Latina Sexualities: Pero no soy una maquina! compares the New View vs. the DSM classification of sexual problems and where each classification schema centers the causes of women’s problems: Within the individual vs. with external forces in an individual’s life. She provides examples of Latina women with a history of sexual abuse or shame for whom the DSM does a poor job addressing the causes sexual problems, and she shows how the New View fits better. Yay! One client, Sarita, told Dr. Fontes her frustration with her pushy priest and doctor – they were urging Sarita to have sex with her husband, even though she was dealing with abuse triggers which made her uninterested in sexual activity. (Sound familiar to anyone?) This experience resulted in the expression contained in the title, translated as “But I am not a machine!”
So Dr. Fontes’ comes down pretty hard on a diagnosis of sexual dysfunction, at least for sexual abuse clients:

The “dysfunction” categories of the DSM-IV imply pathology as a variation from a theoretical normal pattern. It is more helpful to use an injury model – that connects suffering with the environment in which it occured an dthe person who caused it – than an illness model, which locates the source in the sufferer (Lamberg, 2000). An injury model implies recovery for victims of abuse. Yolana is on the mend – being labeled as “dysfunctional” at this time cannot help her recovery (36).

So for another client, Yolanda, a diagnosis of sexual dysfunction is a poor fit or outright counter-productive. But what about women like me, for whom incorporating the label “Dysfunctional” is part of my recovery – if you can call it a “Recovery” at all. At what point are you recovered, knowing you can never go back to the “Normal” which you once had? It may be worth noting here that according to Dr. Fontes’, Sarita did not meet the criteria for PTSD (35). But what about if she had? We get a clue as to Fontes’ feelings regarding an illness model in general with the following line:

“Using the New View, we are able to consider and treat Sarita’s discontent in its historical and current relational contexts, without reducing her to a body with a dysfunction, as if she were a broken machine” (35.)

Emphasis mine, because the problem with this statement is No no you know why am I even still doing this I am not doing this anymore I should not have to explicitly spell this out: If you think that diagnosing someone with a sexual dysfunction reduces them to a broken body, like they are a broken machine, then that’s your problem! Except that then it becomes my problem because then I have to struggle against this idea that there’s something wrong with me not just for having sexual problems but for needing medical help addressing them. You can have a sexual dysfunction and still be a rich, individual person. There has got to be a way to support abuse victims without using disablist language, especially since some abuse victims may very well have chronic illnesses – in fact, folks with chronic illnesses are more likely to be abused.

The third part of the book details the origins of the New View and contains more supportive materials. It’s the biggest and the most difficult section.

The longest chapter in the third section is Dr. Tiefer’s essay, Arriving at a “New View” of Women’s Sexual Problems: Background, Theory, and Activism. It’s very similar, even parallel, to Sex is Not a Natural Act. If you don’t have time to read all of Sex is Not a Natural Act, you could probably get a good idea of what it’s all about from reading this colorful essay. Dr. Tiefer shares her perspective of the history of the medicalization of men’s sexuality (and by extension, women’s,) the influence of Masters & Johnson’s human sexual response cycle research, criticism centering orgasm as the endpoint of sexual research, etc. This essay provides a lot of background information about why and how the New View Campaign came to be in the first place at about the turn of the millennium – with Viagra approved and prescribed, Dr. Tiefer and feminist colleagues wanted to challenge the supremacy of male-focused medicine defining what constitutes female sexual dysfunction, (no skeptic quotes from me) but they had to do so under time constraints – there was a sexual dysfunction conference a-brewin’.

Remaining chapters in this third section address gender and gender roles, sex education and coming of age, lesbian sex therapy, female sexual dysfunction, etc. The essays on lesbian sex therapy were interesting and they draw attention to this often-marginalized group, but even the authors seem disappointed by what they have to offer to their lesbian sex therapy clients. Much of sex therapy is informed by the work of Masters & Johnson and is heterocentric. You may think the same principles in heterosexual sex therapy should apply to same-sex couples but in practice, it frequently cannot. In response to the failures of Masters & Johnson’s sex therapy models, Marny Hall once tried a revolutionary therapy with lesbian clients that she called “Anti-sex therapy,” (168) with disastrous results.

As was the case in Sex is Not a Natural Act, I found myself tripping over problematic elements in these later chapters, which made it difficult to find redeeming elements. Jennifer R. Fishman and Laura Mamo in their essay What’s in a Disorder: Cultural Analysis of Medical and Pharmaceutical Constructions of Male and Female Sexual Dysfunction (about exactly what it sounds like) describe prescription drugs as,

…fast becoming popular consumer products, a capitalist fetish, where one is encouraged to think of such drugs as a means through which to improve one’s life. The shift to the biomedicalization of life itself is indicative of a cultural and medical assertion that one’s life can always be improved” (182).

(Emphasis original.) There is no consideration here for folks who need prescription drugs for mental illness or chronic pain or for folks who cannot afford much-needed medication. What stung me the most was the complete erasure of my existence as a once-adolescent young lady with sexual dysfunction when Deborah L. Tolman explicitly stated, “Female adolescent sexual dysfunction is an oxymoron” (197.) How am I supposed to react to that? Is this slap in the face supposed to snap me out of my reverie? I came away from many of the later chapters feeling very much as though some of our bingo board squares were staring me right in the face.

Overall, it is a challenging book, esoteric, though for readers of this blog it might be one worth reading. But it should be taken with a grain of salt — The New View may not be the panacea for women’s sexual problems it was hoping to be. In breaking away from the problems contained in the medical model, the New View stumbles into and creates new, different problems. It could be strengthened with revisions following a deeper understanding of disability activism and the potentially harmful consequences of stigmatizing both illness and medicine. The goal of the New View is to recognize that sexual problems are often caused by forces outside the body, and then to work for social change to address the causes for these problems. But social change takes time, and some of us cannot wait that long for revolution, especially when there are so few support structures in place to begin with. Some of us genuinely do have sexual problems that originate from within. Some of have problems that are so complex, we cannot isolate the body from the social, and we should not have to choose between social change or medicine. This really isn’t an either-or situation; people want better sex education with which to make good sexual choices and access to medical options. Others face problems so widespread that even feminism can’t fix everything. We have problems and dysfunctions now. While I can see some merits to social construction in looking at sexual problems and dysfunctions, overall with regard to the New View, I remain unwilling to co-sign.

Let’s Read Books – Sex is not a Natural Act, conclusion and final thoughts

04/20/2010 at 10:36 pm | Posted in Uncategorized | 1 Comment
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Well everyone, I did it. I finished reading the feminist & sexologist text Sex is not a Natural Act and Other Essays. Three months and 244 electronic annotations & highlights later, bloggin’ all the way. I felt a huge sense of relief upon completion. My brain is fried, so finally, I can settle down, decompress, play some video games and read a fun book! …Just as soon as I get to bloggin’ the last section…!

The last section in the book is titled The Creation of FSD. These five essays were written in the late 1990s and early 2000s. Actually, I don’t have much to say about the final chapters individually, and I am anxious to articulate my final thoughts on Sex is not a Natural Act as a whole.

Although I learned a great deal about social construction, feminism (especially second-wave feminism,) and the modern history of sexual medicine from Sex is not a Natural Act, my understanding, experience and opinion of female sexual dysfunction remains largely unchanged. Sex is not a Natural Act is a feminist response to sexuality and medicine, but I certainly hope it is not the only feminist response. I feel that there are several points which need improvement. In fact I’m frustrated that Tiefer rarely, if ever, seemed to consider the other other (othered) side of the equation. In shielding as many women as possible from receiving the diagnosis of and medical treatment for FSD, much of what Dr. Tiefer says is alienating and stigmatizing to me, someone who benefitted from that very type of intervention.

What I mean by that is on the one side we (supposedly) have goons in white lab coats promoting quick & e-z, if expensive, medicalization as the solution to all of our sexual health problems. On the other side stands feminism, social construction and anti-medicalization. According to Sex is not a Natural Act, the two positions are incompatible. The media serves as mercenary in this sex war, serving both sides. The talking heads on the side of mainstream sexual models and medicalization far outnumber the feminist & sociological sexologist journalists, but I think it is the feminist counter-attacks that cut me the most deeply.
And trapped in the gulf separating the two, the no-man’s land, are all ordinary folks who experience sexual problems. Who do you trust? Here in the gulf too, is is the third perspective – someone like me – for I’m a feminist living with sexual dysfunction, and ultimately I am the one who is burned by the fire from both sides. Dr. Tiefer does a good job looking out for women who in her judgment do not have sexual dysfunction, but in doing so, her work inadvertently stigmatizes those who do identify with the term. And I fear the strong anti-medicalization stance with little or no wiggle room for those who can be treated with medication makes getting effective treatment (and respect & understanding from peers and doctors) harder, even for the minority who would benefit from that option.

So I don’t have much to say about these last five or six chapters because: The last section of the book is a relatively smooth, easy ride. The bulk of the challenges – figuring out how to decipher Tiefer’s writing style, learning about social construction, tamping down on my own rage-rage-rage reactions – are behind me, in the earlier sections of the book. Most of the essays in the last section were written for laypeople and an audience outside of academia. That means there’s less academic jargon and less re-reading of passages for me. Nonetheless, there’s still some far-out there statements, for example, “The impact of all these long-lasting hard erections on women’s anatomy, women’s preferences, and women’s well-being is unknown” (location 2774). Even with the context of this quote available to me (the purpose and use of Viagra,) I still don’t understand what’s suggested here… frequent intercourse with an erect penis alters a woman’s anatomy, craving for erect penis, and sense of well-being long term?
The last section of the book is short – on the Kindle E-book version, the last section starts 75% of the way through, or so it seems at first glance. I thought I was facing a huge chunk of material, but it turns out that the last 15% or so of the Kindle edition is bibliography and index (which is basically useless on the Kindle because the index is micro-print small. Besides, having an index in an e-book is moot since you can use the built-in search feature.) So the last of the written material is actually about 10% of the E-book. Some of the essays in the last section can be found elsewhere online for free, and I’d read the available essays previously.

The first chapter, “Female Sexual Dysfunction” Alert: A New Disorder Invented For Women, is a re-printed article from now-defunct US-based feminist periodical Sojourner: The Women’s Forum. (As of the time of this blog post, unfortunately Sojourner’s website no longer exists and their archive.org backup does not include full text of the article in question.) I’m not too fond of the title right off the bat for reasons that I’ve probably harped on about on this blog before. (Notice that FSD is in scare quotes. Two little grammar punctuation marks inadvertently nullify even my experience of FSD as a falsehood.) To put it briefly, the Sojourner article is a call-to-arms to protest a medical conference on FSD held in Boston in 1999. In the article, Dr. Tiefer asked, if the doctors and drug companies were truly so interested in women’s sexual well-being, then why weren’t feminists and representatives who could speak for women included in FSD research? (location 2782). The conference nonetheless took place.

The next chapter, A New View of Women’s Sexual Problems by the Working Group on a New View of Women’s Sexual Problems, can be found online in two parts at Our Bodies, Ourselves. This is Part one, this is Part two, so you’ve got the full text there. It’s a brief summary of an alternative, feminist perspective on women’s sexual health problems. It looks fine on paper, right? Well I believe that there is still room for improvement, particularly in the execution.

The third chapter, The Selling of “Female Sexual Dysfunction,” can be read as a follow up to the first chapter in this section, and as a feminist response to the big 1999 conference on sexual dysfunction. The essay was printed in the Journal of Sex and Marital Therapy in 2001, but the text reads as a speech. I’m not 100% certain that it was given at the conference in question though – I know Dr. Tiefer attended and gave a presentation but I can’t confirm that this is the one. There’s two quotes in this essay I’d like to draw your attention to. When addressing readers (presumably conference attendees,) Tiefer states, “Fortunately, women started not only the women’s liberation movement, but the consumer movement” (location 2876). Then, “As both a feminist and a sister researcher, then, let me call on you to include these five issues in your research:” (location 2881).
I’m going to articulate some of my final thoughts on the book as a whole here in the middle of the post.
I’m interested in focusing on something other than the five areas to be considered in future research, but they’re important and the real reason Dr. Tiefer wanted to get the conference’s attention in the first place. So if you’re curious, the five areas can be summed up as: studying all sides of medical intervention for sexual problems, looking outside of a bio-mechanical model of sex, not caving in to commerce, remaining critical of scientific studies, and opening the field for study by non-doctors. There’s actually a sixth point too, integrating feminist studies into sex research (Locations 2882-2992). Which is all fine & dandy.
But there’s one thing about these two quotes that tripped me up while I was reading. And that thing is…
Waaait a minute… “Sister researcher?” As in… some grand sisterhood of women? Of feminism? What sisterhood? A sisterhood among researchers only? Whose liberation movement? Are you my sister? These were two key words that made me think of Renee, who recently has had to write, for what must feel like the hundred millionth time, that she is not a feminist, there is no but, so don’t confuse her with one. She’s not part of that sisterhood. Why would Renee do that?
A long-term criticism of feminism is that the history of feminism (especially that which developed in the USA) hasn’t been very kind to marginalized women. The history of feminism largely favors white, able and cis-bodied, middle class women. Women who do not match that description are still to this day excluded from feminist activism, sometimes deliberately, sometimes as a function of privilege. (Admittedly, I could probably be doing a better job of reaching out to marginalized women too.) Believe it or not, there are feminist icons of historical importance who have made racist, classist and/or transphobic statements. So bear in mind that many women do not identify as feminists and do not identify as part of any monolithic sisterhood… and not because of stereotypes of feminism perpetuated by the media. It’s not always because the media says feminists are all a bunch of hairy-legged man-eaters. Rather, not all women identify as feminists because feminism has burned them. That is a carefully thought out, calculated, conscious decision: rejection. Because feminist icons erased women whose experiences did not match their definitions of what feminism stood for.
So these two quotes, combined with some additional statements throughout the book, make me think that perhaps Dr. Tiefer’s type of feminism is not as inclusive and welcoming as it could be. It should be welcoming to all; however, I certainly do not feel safer after Dr. Tiefer speaks out on my behalf. This is in spite of the fact that she does acknowledge the importance of considering race and class on society and sexuality, and even though she does think about the sexual health & well-being of LGBT persons – at least in her academic writing. It’s a bummer chug along reading about theory that’s all well & good on paper, then to trip over stumbling blocks in the execution.

One area where I’m tripping up in the execution of a new, improved view of women’s sexuality, is on several instances of ablist language throughout Sex is not a Natural Act. Little instances of ablist or at least questionable language appear at multiple points throughout the book, particularly with regards to mental illness. It’s not meant to be inciteful – I think – pretty sure it’s just privilege – but little flippant uses of ablist terms like “Crazy” can add up over time. I lost track of how many ablist statements there after awhile – and keep in mind that these essays were written over the course of many years. So unfortunately, it’s not a bug, it’s a feature, and an area where there’s room for improvement.
On the one hand, the fact that I notice the ablism throughout the book is partly because I myself am aware of people with disabilities as an oppressed group, a point of view made prominent recently by the participants of FWD, and prior to FWD, disability activists on the internet at large. But FWD, and the feminist blogosphere as we know it, did not exist while Dr. Tiefer was writing most of her work. However, Dr. Tiefer has been a feminist activist and a psychologist for more years than I have been alive. It’s clear to me that she’s very well read and has done her homework. In all that time, did she encounter critiques of feminism by people with disabilities? Maybe, something just like this interview with Anna?
On another hand, the picture becomes even more complicated if we are willing to entertain the idea of FSD as a disability in and of itself (an interesting, new-to-me idea which I cannot claim as my own.) This is a very different perspective, and one that even I struggled to accept – precisely because Dr. Tiefer’s work so far has made it so hard to consider. So it’s still new to me and I’m still thinking about how this alternative view would work as a theory & in practice. Yet this FSD-as-disability may very well make sense for at least some people, seeing as chronic pain falls onto the spectrum of disability, and sometimes disability & sexual expression overlap.

The fourth chapter is a bit meta – It’s a book review! Book Review: A New Sexual World – Not! is a review of the 2001 version of For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming your Sex Life. What a coincidence – I have a copy of For Women Only! I have the revised 2005 version of For Women Only, which changed the subtitle to, A Revolutionary Guide to Reclaiming Your Sex Life – the Sexual Dysfunction part of the title was removed for some reason. So we don’t have the same exact copy, Dr. Tiefer reviewed the 2001 version. I’m wondering if she maybe got a preview copy that was altered a bit more before it’s final release?
Unfortunately I am caught with my pants down, as I have the book, but haven’t gotten around to reading the whole thing yet. But since Dr. Tiefer and I are on the same page with having access to a book, I took some time to skim through and see what she was so skeptical of.
And here again is where some of my final thoughts come out, in the middle of the post instead of at the end:
The introduction to the revised edition of For Women Only says that the authors don’t take an exclusively medical perspective when treating their patients. At their practice, “Most problems tend to have both medical and emotional roots, and feed on each other” (Berman & Berman, xiv). They’re willing to use medical intervention AND sexual psychotherapy. Which is more like the balance I’m looking for in addressing FSD. According to Dr. Tiefer, sexual problems are treated with either one approach (medicine) or the other (sex therapy) exclusively, and never the twain shall meet. I interpret Dr. Tiefer’s position as pushing for an exclusively therapeutic approach without the involvement of medical doctors. This is because non-biological problems “Account for the lion’s share of women’s sexual problems,” (location 2785) so if you fall into the minority with a diagnosable physical problem, I can only conclude that you’re a minority of little interest. So I interpret Dr. Tiefer’s approach as pushing for a one-size-fits-all social construction treatment in much the same way she claims doctors push for a one-size-fits-all biological approach to FSD. Neither way alone works for me; I need both. In practice I’ve been doing the social construction side alone, on my own, through a feminist lens.
And in looking through For Women Only, some, but not all, of the patients have both physical and intangible (emotional, relationship, etc.) problems which complicate their sex lives. There’s a duality that might benefit if addressed from both sides instead of one side exclusively. Nicole had surgery for vulvar cancer (Berman & Berman 2005, 4) as well as relationship problems and insecurity with masturbation. Paula had cancer and was treated with multiple surgeries, including surgeries in her pelvis (2005, 11). An anonymous patient went through surgery for vaginal prolapse without actually having vaginal prolapse (pressured by her boyfriend,) and lost sensation inside of her vagina (2005, 16). Gail had never had an orgasm, but she did have vulvodynia (2005, 39.)

For example, in the one case study Dr. Tiefer focuses on, new patient Nicole noticed sexual side effects following laser surgery for vulvar cancer, and use of antidepresants. Not tricyclic antidepressants for pain either; we’re talking about SSRIs which can sometimes have sexual side effects (Berman & Berman, 2001, 4). So I honestly do not see how medical intervention for sexual side effects following pelvic surgery and use of SSRIs is inappropriate. I mean, what a coincidence, I had vulvovaginal surgery too and yeah, things feel different down there now. I don’t miss the excess nerve endings and I still self-lubricate when aroused (maybe not as much as I used to, but that’s what bottled lube is for.) For Nicole maybe having surgery so close to her nerves wasn’t a good thing. So how is medical examination and intervention not an appropriate post-op treatment to offer to cancer patients? Especially since Nicole had laser surgery. Now I don’t know if this is true of vulvar cancer, but what I read in the journal articles suggested that, IF you must go through a surgical approach for vulvodynia, talk to your doctor and see if you can avoid lasers.
Nicole’s treatment wasn’t limited to medical intervention, but she couldn’t be given long-term sex therapy counseling at the Berman clinic, probably since it’s so far away from her home in Kentucky. So in addition to a prescription for Viagra, Nicole was “Referred to a trained sex therapist in her hometown for further treatment” (Berman & Berman 2001, 8).
None of this is satisfactory to Dr. Tiefer and she runs down a long list of criticisms with the handling of Nicole’s care under the Drs. Berman, followed by a more general critique of For Women Only. She expresses a hope that For Women Only is just a flash in the pan while the ubiquitous feminist health text Our Bodies, Ourselves book continues to sell. The same Our Bodies, Ourselves that as of 2005 printing has about 1 & 1/2 pages on vulvodynia. In fairness, OBOS is currently working on a revised edition which will maybe, hopefully contain more details on sexual health problems that do not make up “The lion’s share of women’s sexual problems” (location 2785). Because I gotta tell you, it’s real frustrating and time-consuming (needlessly so) to not be aware of medical factors that can make sex turn out to be a bad experience. Dr. Tiefer claims that “The message of the Berman’s book is that… there’s more to know about (and worry about) in your genital neuroanatomy and blood flow than you’ve ever dreamt of” (location 2908). So to her, the book is designed in such a way as to make women worry about all the things that can possibly go wrong downstairs. Meanwhile, I wanted to know everything about my own anatomy, because I couldn’t even identify what was causing my pain at first. I like one of the lines in the intro for The V Book… “Your Private Parts Shouldn’t be Private to You” (i).
Basically, I still cannot reconcile Dr. Tiefer’s anti-medicalization stance with the fact that every once in awhile, women with FSD genuinely benefit from medical intervention. The anti-pill sentiment freaks me out because I don’t know if the sentiment extends to managing chronic pain. But even if it doesn’t – I still can’t dismiss from my mind the way other women who do not have pain but do have other sexual problems must feel. Why should I be helped but not them?

Last chapter in this section, and it’s a short one. We’re almost done now. The Pink Viagra Story: We have the Drug, but What’s the Disease? is one of the newer essays, printed in 2003, and can be read as a brief recap of the history of the medicalization of sexuality, with a splash of culture & current events mixed in. I think the most interesting part of this chapter is the slow creep of women’s sexual medicine. It’s 2010 now, and this essay was written 7 years ago, but there still isn’t a magic pill for FSD. Turns out diagnosing women’s seuxal problems wasn’t as easy as everyone expected, and “This has led to scientists’ epiphany that women’s sexual lives are contextualized, that is, that sexual experience depends as much or more on social context (relationship, cultural background, past sexual experiences) as on genital functioning” (location 3023). However, men still get to enjoy the benefits of male privilege so the context of the formation of men’s sexuality is ignored (location 3030.) I would say that that context is at least in part, what is now called Rape Culture by some feminists. The book doesn’t say that, but I think that’s what it’s getting at. Anyway, the quest for Pink Viagra continues. (Really, though, I think much of the quest for Pink Viagra depends on people not understanding how Viagra works in the first place. According to Violet Blue, regular ol’ blue Viagra has the same effect on women as it does on men. It’s just that cis women don’t have a penis, which when erect is considered a visible sure sign of arousal & desire. Even if that’s not why it is erect.)

And that’s pretty much all. There’s a short conclusion, We Need Theory, We Need Politics, which much to my own surprise acknowledges the importance of understanding “How psychology, biology and society interact and change” sexual excitation (location 3554). There’s some case studies of Dr. Tiefer’s clients cited as examples of problems in US sexual culture. Basically in the end, there’s still a lot of story left to be told. Dr. Tiefer offers a little advice on where to start studying sexology and tells the reader to “Figure out how those gender theories actually apply to yours sexual desires.” (Location 2074). Okay. Can we get some practice going too? Can we see how these theories actually apply to real life?
That’s basically what I’m trying to do with this blog. Figuring it out. Working on it. I’m still under 30, so I’ve got plenty of time…

And sometimes, all those theories… don’t do a very good job of applying to me. Sometimes they do! Sometimes sex & gender theories are great! Sometimes I appreciate being able to look at FSD through a feminist lens! But sometimes, to someone like me, maybe some of the theories… not so much. I recently read this very interesting essay by Carol Hanisch, better known now as The Personal is Political. And I’m still mulling it over in my mind and reading interpretations of what the essay meant. But one line in the introduction to the essay explains,

“Political struggle or debate is the key to good political theory. A theory is just a bunch of words— sometimes interesting to think about, but just words, nevertheless—until it is tested in real life. Many a theory has delivered surprises, both positive and negative, when an attempt has been made to put it into practice.” (Hanisch, online.)

So to me, I think that revising the dialog on FSD has yielded some unexpected, and, at times, unpleasant surprises.

But what right do I have to complain & critique in the first place? Let’s face it – I’m no expert on sex; I have very limited experience with any sex. I have no relevant credentials to my name, no Ph.D., no M.D., no relevant degree, no published books, no license (except to drive,) no medical authority. I cannot offer advice, merely perspective… And even that perspective is skewed. I’m a regular person with female sexual dysfunction. All I have is this blog and a history of pelvic pain problems. A blogger with sexual dysfunction, which some sex & gender theories state is an invented falsehood and from which I believe stem some very ugly statements about FSD and the women who live with it. Can anyone then trust me, take me at my word, at face value? Or have I been brainwashed by the media and the phallocentric medical community and so am a lost cause, a casualty, collateral damage.

Yet I am compelled to speak my experience aloud, though it flies in the face of mainstream wisdom. In doin’ things different, I may very well be doin’ it wrong. It wouldn’t be the first time.

Whew. What a trip. That certainly was a journey into reading. Finally, so far when I finish books for book review purposes, I like to suggest who might be interested in reading the work in question. For Sex is not a Natural Act, I think that the target audience is primarily feminists, sex therapists and/or sexologists, college students and teachers. I’m not sure if it would be appropriate for everyone living with sexual dysfunction. It sure wasn’t easy for me to get through, that’s for sure. Maybe the book would be of interest to people with sexual dysfunction who already have at least a basic knowledge of feminism or a budding interest in it. I’m not sure I’d advise going in without some scaffolding to build on.

But you want to know the worst part of finishing Sex is not a Natural Act…?

Cover for New View book

[Description: A white lady's hand holding a green-and-purple book over a yellow background. The book is clearly titled "A New View of Women's Sexual Problems.]

There’s another book just like it!
“There is another Skywalker!” Omg, you guys, come on, you guys. You’re killin’ me over here. You can’t be serious! There’s more?? I have do this all over again??

Okay, fine, I will read this. I will do this task. But not right now. I need to chill out for awhile & read some fun books first. Looks like I’ve got a lot left to learn… I wonder though, if perhaps anyone else, has something of value they can learn from me, too.

Let’s read books part 4 – more Sex is not a Natural Act

03/30/2010 at 8:07 am | Posted in Uncategorized | 1 Comment
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Part 4 in our continuing series following my progress through the Kindle edition of the feminist & sexologist book, Sex is not a Natural Act and Other Essays, by Dr. Leonore Tiefer, Ph.D. Need to catch up with our story so far? See parts 1, 2, and 3… but be warned! I have a lot to say about this book, so the posts get pretty long.

While most of the Sex is not a Natural Act has been relevant to my interests all along, we’re getting into some particularly interesting, thorny and exhausting areas now – like section 4, the Medicalization of Sexuality. That relevancy to my interests doesn’t necessarily mean I agree with or endorse all of the author’s statements – often times I find myself antagonized by what the author says about medicine and sexuality, and so I question or outright disagree with some of her positions, even while I acknowledge the value of other statements. The Medicalization of Sexuality is another section heavy on academic theory, but there’s some practice tempered within, based on author Dr. Tiefer’s experience working in a urology department as a psychologist assessing men dealing with erectile problems, and her work as a sex therapist.

I had a lot to say just about the intro to this fourth section of the book; it’s a long introduction. I feel like I’m wasting time by arguing with the introduction to a section of the book. Like I’m just arguing semantics instead of substance… But there’s so many statements in the intro that stood out to me as being in stark contrast to what I’ve experienced.

If you haven’t already burned through your available Google Book preview, why not follow along? Well, let’s get this show on the road…

We start off with a very clear, no ifs ands or buts statement on Tiefer’s position on who should be in charge of understanding sexuality, and it isn’t those with a background in medicine and anatomy. I’m a bit spooked by that actually; for starters, if the medical model of sex is Tiefer’s “Arch-enemy,” (location 2036,) how does she handle patients with what she considers to be the one valid & important form of sexual dysfunction, pain, which has the potential to be treated medically? We have some clues: She says, “For me, medicine is the proper framework when a definable disease condition with a physical basis requires someone expert about the body. This is not very often what is wrong, however, when people are unhappy with their sexual lives” (location 2042, emphasis mine.) Okay, so when someone has a disease condition, it’s appropriate to consider medical intervention.

But in light of the specter of medicalization, in which normal, common human experiences are needlessly complicated by medical intervention, how do we know that what we’re dealing with is a real disease condition vs. something that a bunch of goons in white lab coats just made up?

How often does a distressing medical problem that can be treated by a medical doctor have to happen within the general population for it to be frequent enough to be worth acknowledging? The window must be very narrow. If the prevalence of a problem is high then it’s not to be considered a problem at all - “If half of the women in the country have a problem, it’s not a problem by definition” (Smith, online). Ooo… That’s maybe not the best choice of words… To give the benefit of the doubt, I’m sure she would never say something like that about any of the other widespread social problems that large percentages of women experience in the US and globally.

Limiting ourselves to a discussion of sexual problems, vulvodynia for example may happen to ~about 15% of the female population in the US, according to the Dr. Oz program that aired in January 2010, and I’ve seen similar figures cited elsewhere. That’s far from a majority of the population, certainly, but it’s still unnervingly frequent to me, especially since it’s still a taboo topic. But on the other hand perhaps not all of those patients are unhappy with their sex lives, and maybe they are able to cope well with their daily life with vulvodynia.
Is 15% too small to consider? Or is it too big and therefore an acceptable variation of normal which does not merit medical attention?

What are we talking about here? Vulvodynia is a cause for dyspareunia, but we don’t usually think of it as disease in and of itself. It’s better thought of as a syndrome, a collection of overlapping symptoms. But perhaps I’m being overly picky; under a very broad definition of “Disease,” it counts, but takes on additional stigma. Still, for the purposes of this discussion, it’s probably ~fair enough to consider vulvodynia a “Disease condition.” For me at least, there was something happening inside my body that was, and to some extent still is, causing the vulvar vestibule cells and pelvic floor muscles to act out.

Yet I’m not totally at ease – what about other health problems that aren’t well understood? What are some examples of “Disease conditions” warranting medical treatment? What about controversial diagnoses? If certain conditions are still not well understood and accepted by mainstream media and medical professionals, should they be left to non-medical professionals to analyze and deal with? I think it’s a relevant question, as vulvodynia is sometimes accompanied by overlapping conditions which are not all fully understood or treated seriously.

So what happens when you have one of the definable disease conditions with a physical basis that requires an expert on the body? I don’t know. Tiefer herself acknowledges that dyspareunia is the one valid, important form of FSD, but I contest on that claim on the basis of setting up an artificial hierarchy of what’s “Real” and what isn’t. Who is to say another woman’s anorgasmia or low libido is less valid & important than my pain? Plus I haven’t been able to reconcile the demonization of doctors, urologists, and Big Bad Pharma with possibly referring patients to them for medical treatments when appropriate.

I cannot reconcile statements like, “The corporate sponsored creation of a disease is not a new phenomenon,1 but the making of female sexual dysfunction is the freshest, clearest example we have” (Moynihan, online) with the fact that I have FSD.

Tiefer continues in this vein when she says that ultimately, medicalization in and of itself makes people more unhappy than whatever problem motivated them to visit the doctor in the first place – because of all the treatments, tasks & self-monitoring they have to engage in, and because if an individual does not see progress, zie is likely to be blamed for doing something wrong (location 2055.)

Now unfortunately, I too have experienced this “You must be doing something wrong” blaming from medical doctors – when I first noticed symptoms and made a few visits to my original gynecologist, he insisted that the pain must have been psychosomatic. He insisted that I was making myself feel pain because I couldn’t relax, so have a glass of wine and relax. Mind over matter…
But of course, the pain I was going through was probably not due to any action or inaction on my part – and even if it was, there’s no way to prove it now. This blaming incident was due to the fact that my original gynecologist was an asshole, and like still too many other gyns, he was ignorant of causes of & treatments for chronic vulvar pain. This incident could have potentially been avoided if there had been more and more widely published medical research on dyspareunia, and if he had kept up with such research.
I have talked to other women who have likewise been blamed by their doctors – or psychosexual counselors & therapists – for their lack of progress. However, this phenomenon of blaming isn’t limited to medical settings; it’s also seen in DIY self-help culture. So I’m not convinced that patients who identify as having sexual dysfunction would truly be so much better off looking for help & understanding elsewhere, either. My concern is that this anti-medicine backlash could push folks with sexual dysfunction (and any other number of chronic health problems) into the waiting arms of other dubious so-called experts and quacks.

See what I meant when I said I had a lot to say just about the introduction? Let’s move on to the meat & bones of the section and look at a few highlights…

The first true chapter in the fourth section, Sexism in Sex Therapy: Whose Idea is “Sensate Focus”? is one of the shortest chapters in the book. Despite the title, I didn’t interpret it as an outright condemnation of sensate focus, which is an exercise frequently used in sex therapy, recommended by Masters and Johnson. The sexism in question comes from a critique the Masters & Johnson model of sexuality, which Tiefer expounded on earlier in the book – she believes that their research on human sexuality was inherently biased in favor a male model of sexuality. Tiefer relies heavily on Shere Hite’s research on women’s sexuality, and suggests creating alternative sex therapy exercises to cater to women, such as “Emotional homework assignments (heavy on loving communication, eye contact, expression of feelings and the like)” (location 2094). I agree that an alternative therapy could be beneficial for some individuals and couples attending sex therapy – I can definitely see that working for some folks. I do not see alternative therapies as adversarial & in conflict with one another – if one doesn’t work, try another, or, if you need one type of therapy more than another, then go for it.

Most of the second chapter, Women’s Sexuality: Not a Matter of Health, is dedicated to talking about the social construction model of sexuality, and the very last section turns to the history of men’s sexuality as it relates to medicalization. In Not a Matter of Health, Tiefer continues to fight against the medical model of sex, in a response to classifying sex as a matter of health and nature. For example, in the greater context of talking about how health is a social construction (something I’ve seen amandaw talk about in greater detail,) Tiefer says, “Yes, we all are born and die, and in that sense, biology dominates, but how we use and experience our bodily potentials in between those bookends is no more dictated by biology than is the style of our hats” (Location 2108). Yet I cannot help but think that an individual’s life experience is likely to be shaped in part by zie’s own biology… and by the way that that individual’s surrounding culture is prepared to deal with it. Everybody else is wearing hats, too, and not all of them are ready or willing to have their hats changed. If you don’t match that culture’s definition of health, you may find yourself limited in what you experience. And at this current state of science, you can’t change your own biology with the same ease as changing at hat, nor cultural expectations be changed overnight (oh but if they could…) so what if you don’t have enough spoons left to walk over to the closet or store to switch hats?

There’s more to this chapter but I’d like to draw attention to one of the last bits. Tiefer states, “As feminists, our efforts on behalf of women’s sexuality should be in terms of providing and financially supporting education and consciousness raising rather than health care at the present time” (Location 2188). And again here, I think we have a matter of unfortunate timing in light of the fact that the US is currently embroiled in healthcare reform. I do not see how health care and women’s sexuality are in direct conflict. There’s room for both and I, for one, need both! I need healthcare! Health care, and healthcare, is a feminist issue! I wrote about my experiences dealing with vulvodynia and healthcare months ago! How is that not a mingling of sexuality, sexual health and health care?

The next chapter, The Medicalization of Impotence: Normalizing Phallocentrism is sort of available online, if you have access to educational databases. It was written before Viagra was readily available, and it picks up where the last chapter left off, talking about the history of men’s sexual medicine, erectile dysfunction and impotence up to that point. Most of this chapter is informed by conferences and written material on men’s sexuality and sexual health. This chapter also describes in detail the very specific demographics of Dr. Tiefer’s male patients at her urology department. She then describes four groups of people who are heavily invested in upholding the medicalization of men’s sexuality; briefly these are “Urologists, medical industries, mass media, and entrepreneurs” (location 2226). Patients themselves are not necessarily excluded as stakeholders in whether or not erectile dysfunction is looked at medically or holistically (for never the twain shall meet,) for she includes self-help groups under the category of entrepreneurs (location 2278) and later talks about the patients who go to her clinic (location 2285). At many points in this chapter, I found myself wondering what it would look like if the sexes were reversed – what if Tiefer had been working in a clinic that focused first on helping women patients, like in a gynecologist’s office? At one point, she states, “The mantra of sexual medicalization, ‘It’s not all in your head,’ replaces the stigma of failed responsibility with the face-saving excuse of physical incapacity that men often learn in sports and the military” (location 2296.) Ouch. So how would this apply to women? After all, even vaginismus is not all in a woman’s head – yet generally women are not as encouraged to join sports and military service as men are.

The fourth chapter in this section, Pleasure, Medicalization, and the Tyranny of the Natural, is likewise sort of available online, if you sign up for a trial at encylopedia.com. I don’t have much to say about this chapter. Pleasure talks about the importance and complexity of factoring in women’s pleasure into sexology. Indeed, a very strong emphasis is placed on complexity as a theme in this chapter. It sounds as though it is impossible or nearly impossible to understand women’s sexual pleasure, not just because sexual pleasure itself is complicated but because there are various barriers to understanding it – conceptual, physiological, political, and medical (location 2356). This chapter is also the first in which I saw Tiefer address the APA’s incorporation of “Personal distress” to the definition of sexual dysfunction. Tiefer concludes that the bit about personal distress being important for evaluating sexual dysfunction is inadequate,

“If the authors were truly interested in women’s personal distress, they would have incorporated many other psychological and interpersonal items. As the purpose of the reworking seemed to be to provide ‘clearer specification of end points and outcomes… for clinical trials’ of new pharmacological agents, it seems that considerations of pleasure would only introduce the kind of complexities discussed earlier” (location 2425).

And then towards the end of the chapter she includes a link to her website campaign (Google it) as an alternative way of looking at women’s sexuality.

The last chapter, Sexology and the Pharmaceutical Industry: The Threat of Co-optation is a long one, (about 8% of the Kindle book) and provides a recent (like 1950s-early 2000s; especially the 1980s and up) history of medicine in general. That means there’s no talk about the old timey diagnosis of hysteria and frigidity in this chapter. The history is interesting and exhausting, yet I have a few suggestions for additional material in the unlikely event that it’s ever revised. I would recommend including a history of the insurance industry’s role… And a discussion about prescription birth control for women. It’s somewhat odd that in a chapter about the history of medicine, especially as it relates to sex, there is nothing about the research that goes into producing and then aggressively marketing hormonal birth control, and all of its potential side effects. This omission is regrettable since so often, the responsibility of birth control falls onto the shoulders of women, but that responsibility can carry problems – health, sexual, and relationship – of its own. Dr. Tiefer’s goal with this chapter is to warn members of the field of sexology that their noble profession is at risk of being taken over by selfish pharmaceutical interests. To put it briefly, sexology isn’t a well-respected field, and research money from the pharmeceutical industry is attractive, (locations 2520-2564) but compromises integrity (2565-2580). The conclusion lists suggestions for sexologists to follow in order to resist big pharma, and contains more iterations of the social construction model of sex (locations 2660-2720).

There were a few other parts in the chapter I was particularly interested in. For example, when explaining the history of medicine, Tiefer talks about the use of off-label medication, and she cites Viagra for women as an example (Location 2510). It’s not meant to be used that way but some patients and doctors might be interested in it. But off-label use of prescriptions is something I’m familiar with, since some vulvar pain patients likewise use meds off label – tricyclic antidepressants and anti-seizure medication comes to mind immediately. I personally haven’t yet seen any advertisements for the drugs to be used in this manner, but that doesn’t mean that marketing the drugs for treatment of chronic pain doesn’t exist. But that means that sometimes off-label drug use isn’t necessarily harmful, and sometimes, it’s all we got.

A final thought today… At several points in Sex is not a Natural Act, I felt uncomfortable with Tiefer’s language, not just about FSD but about health in general. I thought some statements contained potentially ablist language. (See FWD’s continuing series on ableist language.) It didn’t come up often, it wasn’t glaringly overt, and it’s not outright hateful speech. I think it’s a matter of perspective and privilege, and perhaps again, bad timing. The first one or two times, I wrote it off as a fluke. But when I saw a few more examples, I tripped.

Like, for example, at the conclusion of intro to this 4th section of the book, after remunerating potential problems with using drugs to manage sexual dysfunctions, she asks the reader, “Has everyone lost their mind?” (location 2074.) And at first I thought, okay, that’s a common English language colloquialism… but on the other hand it’s potentially problematic expression when we consider that it’s also manifestation of the expression “To go crazy,” and crazy means mentally ill and mental illness is bad, and is therefore stigmatized, so people who are mentally ill are themselves bad and stigmatized. And that’s the way the expression is being used in this case. Now, someone is sure to say to me about this one little sentence, “You’re thinking about this too hard.”

But there were other expressions I was tripping over too. There’s a few other questionable comments and quotes regarding treatment of mental illness scattered throughout the book. And a little later on, Tiefer says, “Besides its economic potential, sexual dysfunction is an attractive subspecialty because patients are not chronically sick or likely to die from their ‘disease'; there are also opportunities for diverse outpatient and inpatient services” (location 2233, emphasis mine.) Here I can’t help but think to myself… well, with me, with vulvodynia, a sexual pain disorder and therefore the one true & valid sexual dysfunction according to Dr. Tiefer herself, vulvodynia is a chronic condition. While not an infectious disease, it’s probably safe to think of chronic vulvar pain as divergent from what US culture has constructed as “Healthy,” and therefore it falls under a very broad definition of “sick.” Sooo… why yes, as a matter of fact, I am chronically sick. You may notice here that Tiefer’s statement left no wiggle room with a qualifier like, “Most of the time,” or “often.” People with sexual dysfunctions aren’t sick, period. Which really doesn’t work for me because then I’m not allowed to look at sexual dysfunction through a disability lens. This statement also overlooks patients with overlapping co-conditions, which may influence sexual health & expression.

Plus, in practice I’m having a very hard time finding a doctor ready & willing to handle me so how attractive is sexual dysfunction as a sub specialty, really? After all, according to one doctor familiar with treating vulvodynia, “There’s little interest in treating vulvodynia. It’s time consuming, and the monetary awards don’t match the effort required to treat the patient properly” (Purcell, online). And then there was this recent post from The Sexademic talking about doctors don’t get sufficient exposure to sexual health and sometimes when they start practicing, some doctors treat the patients just horribly. Such cruel behavior repels me from many doctors, and seems like it would be counterproductive to starting a sexual health clinic.

Whew. This turned out to be another ridiculously long post and we’ve still got one section left to go, plus the conclusion. Will we make it? Will I survive The Creation of FSD? Only one way to find out. We’re almost there so stay tuned for more adventures in reading.

Let’s read books part 3 – Sex is not a Natural Act, con’t

02/23/2010 at 7:26 pm | Posted in Uncategorized | 1 Comment
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Part 3 in our continuing series on the feminist & sexology book Sex is not a Natural Act and Other Essays. Last time I posted about my journey into Sex is not a Natural Act and Other Essays, I left off at the end of the second section, Popular Writings on the Theme. (See part 1 here.) So far all my analysis relating to the book consists of ridiculously long posts, so if you’re wanting to read along with me, you may want to read my posts in little bits & pieces. Or just burn through, whatever.

After posting part 2 in our continuing series, I got dragged into jury duty and with nothing else to do but read, I plowed through more of the book. It’s time to talk about the next few chapters, the theme of which is Feminism and Sexuality. The six chapters contained in this section takes us to about the halfway point of the book.

My overall impression of the feminism-themed chapters in Sex is not a Natural Act can be briefly summarized as, “Not completely miserable.” There’s valuable thought on feminism and sexuality here, and this section contains my favorite chapter, which is about censorship and feminist analysis of sexually explicit materials.

Unfortunately, Feminism and Sexuality is also a return to heavy academic language and theory:

“Diverse erotic lives and new methods of reproduction are possible because of psychological processes such as symbolization and conditioning that are connected to ever-changing cultural formations.” (Location 1526.)

Oh goddammit.
Thinking caps on, everyone! Oh, you’re all already wearing your thinking caps, and so am I… Better make mine a double then!
By now I’m more used to Tiefer’s academia, but I still needed to re-read several passages from Feminism and Sexuality in order to absorb their messages. And sometimes, even after re-reading sections, I remain unconvinced of Tiefer’s position. Sometimes, I think she’s too heavy on the academia, too willing to sacrifice concrete practice and to overlook real, if uncommon, lived experiences.
And, now that I’ve read ahead and am almost finished with the book, I feel comfortable saying that… I’m  picking up on a couple of potentially problematic areas, especially in language she chooses and some inconsistencies…
Oh well, nobody’s perfect. Let’s dive in and get exploring.

Some of the essays in Feminism and Sexuality, particularly the first essay, are autobiographical. In the first chapter, An Activist in Sexology, the reader gets a better idea of Tiefer’s experience and history as a sexologist, especially as it relates to feminism. This first essay consists of a paper presented to the Society for the Scientific Study of Sexuality in 1993 upon receiving their Kinsey Award. Tiefer describes herself as an activist in the field of sexology, merging academic research, sexuality, politics and second-wave feminism into an expertise that she herself recognizes as controversial.  Tiefer seems to relish her position as a controversial figure, describing two incidents in which she was invited to speak about specific sexual subjects at meetings, and instead talked about completely different (though still relevant to sexuality, and with a strong flavor of feminism) topics (Location 1444, 1476). The gamble paid off in the end, as she is now recognized as an expert in the field of sexology. At the end of her paper she concludes, “There is really no way to be apolitical as a sexologist – every action supports some interests and opposes others,” (location 1490) and she implores others to incorporate feminist themes into their work – particularly “race and class analyses” (location 1491.)

The second chapter, Biological Politics (Read: Propaganda) is Alive and Well in Sexology, Tiefer takes a critical look at gender essentialism as it relates to biological arguments. That is, she critiques claims – including those from within the feminist community – that women and men are different due to their biology rather than differences in socialization & culture: “I have observed that arguments about sexuality emphasizing biological differences between men and women’s sexual lives as well as those emphasizing biological similarities have been used to ignore the sociocultural components” (location 1530). The critique is still relevant today, as some feminists continue to attribute gender differences to sex hormones and/or the presence of what kind of genitals you were born with. Attributing gendered differences to biology goes by different names, depending on what field is popular at the moment, be it “Regional brain anatomy, brain lateralization, evolutionary theory, gene effects, hormones, etc.” (location 1506). Tiefer’s career as a sexologist put her in a unique position, as working in that field allowed her to watch as medicine & biology became incorporated into sexuality research and clinical practice. The results of this biological views are restrictive when it comes to individuals’ sex lives, as under this sort of view, heterosexual intercourse is – or rather, it used to be – the only act that results in procreation and the continuation of the species (location 1525).

Next up is Gender and Meaning in the Nomenclature of Sexual Dysfunctions, and this chapter looks at the gender politics in the DSM - “The DSM, because of its powerful social location and its relations to most of the elements identified above, can be read as a work about gender” (location 1568, emphasis original.) She states,

“The language of the DSM overtly and covertly speaks the language of gender and of the most biologically reductionist version. By using only the terms males and females, never men and women, the gender language fixes people in the world of animals and locates whatever governs sexuality as in ‘the animal kingdom'” (location 1602, emphasis original.)

She doesn’t mention this part, but of course by using terms like “males and females,” the DSM also ignores folks who do not identify as belonging to a gender binary.

Now, in this chapter, Tiefer focused on gender…
But I looked at it from a different angle.
I noted the gender politics, yes, but I also gleaned clues about looking at FSD as a disability in and of itself, under the broad category of mental (and physiological) health. Tiefer provided a brief history of how sexual dysfunction has been treated within the DSM over the last few revisions. Currently, sexual dysfunction is listed in the DSM – this is a hotly contested feminist issue.
However.
Looking at FSD as under the spectrum of mental illness, and thus under the broader spectrum of disability, is a different way of looking at FSD, and one I’ve not encountered much. Tiefer doesn’t do that in this book; she doesn’t look at FSD as a disability in and of itself. In fact, in an earlier chapter, she says,

“Using the clinical standard with regard to psychology is more difficult than using it for physiological matters because it’s harder to prove psychological disease, deterioration, or disability. Who’s to say, for example, that absence of interest in sex is abnormal according to the clinical definition? What sickness befalls the person who avoids sex? What disability? Clearly, such a person misses a life experience that some people value very highly and most people value at least somewhat, but is avoiding sex “unhealthy” in the same way that avoiding protein is? Avoiding sex seems more akin to avoiding travel or avoiding swimming or avoiding investments in anything riskier than savings accounts–it’s not trendy, but it’s not sick, is it?” (Location 240, emphasis mine.)

The “Clinical standard” she’s talking about is the clinical definition of normal, given just a paragraph earlier:

“The clinical standard… uses scientific data about health and illness to make judgments. A particular blood pressure or diet or activity is considered clinically abnormal when research shows that it is related to disease or disability. It shouldn’t matter to the clinical definition whether we are talking about the twentieth century or the tenth, about industrial Europe or rural Africa” (Location 235).

By placing sickness behind sexual problems, in this case avoiding sex, Tiefer is overlooking individuals who are bothered by sexual problems, due to sickness or disability. We’re taking opposite views here. From my point of view and in my experience, the sickness or disability comes before, or in conjunction with sexual problems.
(I also seem to recall reading personal stories from PWD who are pushed to avoid certain activities, including travel cited as an example above, due to society and companies not making their facilities accessible enough. I seem to recall hearing something about airline companies which have refused to serve PWD and other transportation services making travel difficult… In which case, avoiding travel isn’t a sickness in and of itself – it’s part of being disabled. Needlessly so – it shouldn’t have to be like that, if society was willing to be more attuned to the needs of PWD.)

Looking at FSD in and of itself as falling somewhere on the broad spectrum of disability is a very new idea to me and, I think, one that merits further investigation.
It is only within the last few months that I’ve started to look at FSD through the lens of disability, so I’ve got a lot to learn yet. And I’ve only been able to start thinking about it thanks to running into a handful of feminists on the internet who suggested that’s a valid point of view, or who were at least open to the idea of a broader definition.
Basically, I feel like I needed permission to explore FSD as a disability in and of itself, even though living with vulvodynia threw me onto the chronic pain spectrum to begin with. In this regard, those who question the validity of FSD act as gatekeepers, questioning the identification of those who would try to pass through those gates. The narrative goes something like, “Are you certain it’s not your partner’s fault or due to your own body insecurity; don’t you realize that you’re acting as a tool to Big Pharma and the patriarchy; you are too close, too deeply involved with your own lived experience to be able to make a wise objective decision.”
I needed permission to choose my own identity. Why did I need a permission slip? And actively choosing to identify as having sexual dysfunction and thus as falling somewhere on the broad spectrum of disability, is likely to remain controversial, since FSD is so hotly contested, and the women who experience it are so strongly stereotyped & stigmatized.

After all, “Diagnoses listed in the [DSM] manual are generally recognized in the courts in making legal decisions, by hospitals and psychotherapists in keeping records and by insurance companies in reimbursing for treatment (New Psychiatric Syndromes Spur Protest, 1985)” (Location 1561, emphasis mine). The emphasis in that statement is mine, because I have personal experience with this. The IC code for DSM is used in reimbursing pelvic pain patients… 625.x… and I’ve seen some of my friends get diagnosed with code 625.x… I want and need treatment, I need insurance to cover treatment, and so I need that diagnostic code to stay in place. I dread to think that in the worst case scenario FSD, and under it the specific sub-category of dyspareunia, is at risk of being removed from the DSM in future revisions.

But there is more at stake than just myself. There are other diagnostic codes under the broad category of sexual dysfunction listed as well – erectile problems, orgasmic problems, vaginismus… And some of those diagnostic codes are indeed questionable. It’s not all about me, and I do not have all the answers; I will likely never have all the answers. I’m likely to be faced with and generate more questions as long as I continue down this road.
Not everyone wants and/or needs treatment for sexual dysfunction, nor will everyone who experiences a sexual problem identify that problem as a dysfunction. Not every variation from Master’s & Johnson’s Human Sexual Response Cycle is in and of itself a disorder. It’s not fair to slap labels onto people or to force them into anything. One way we can think about when intervention is appropriate would be to ask the individual if zie feels personal distress; however Tiefer would likely point out here that the drawback to asking is that socialization rather than intrinsic factors could be exaggerating the amount of distress an individual would otherwise feel in a different environment.

The next chapter was more palpable to me - Some Harms to Women of Restrictions on Sexually Related Expression is so far my favorite chapter in Sex is not a Natural Act. If you haven’t burned through your Google Book Preview yet, it might be worth spending your available preview on this chapter; I actually very much enjoyed it.  Tiefer states her thesis very early on – “I have concluded that women are in more danger from the repression of sexually explicit materials [including pornography] than from their free expression” (location 1634, emphasis original.) That’s pretty strong, unequivocal language! She says, “The fundamental context of women’s sexuality in our time is ignorance and shame (location 1640, emphasis original,) and that, “Although antipornography arguments seem to rely on scientific research or moral principles, I often see just the projection of these internal feelings of shame and dirt that were taught at an early age” (location 1647). This is still true today! I still hear about this within sex-positive circles!

Basically in this chapter, Tiefer argues that, because women are generally socialized to sexually self-regulate & restrict themselves to begin with, it doesn’t make sense to add to the restrictions women encounter by censoring erotic & pornographic material. These materials have the potential to be harnessed for good, in the form of stimulating the imagination. But wait, what kind of message does it send if a woman watches degrading porn and is turned on by it, is that a long-term good idea? Keep in mind that Tiefer is big on symbolism, she loves it. And instead of interpreting porn literally, she says the other way to look at it is take the symbolic approach -

“The antiporn feminists argue that pornography is to be interpreted in a literal way – if it’s a picture of a woman being fucked while lying across three tall stools in a coffee shop, it’s a picture of an embarrassed, uncomfortable, and unhappy woman. But this isn’t the way sexual fantasy actually works.” (location 1670).

And this is particularly relevant, sine I’ve heard sex-positive feminists try to explain this concept over & over again on thier own blogs – it’s fantasy. That still happens today! As an example, Tiefer cites one of her patients who derived some pleasure (and shame) from masturbating to a sexually degrading fantasy, and Tiefer says,

“Is it correct to interpret this woman’s fantasy as the straightforward story of a degraded and humiliated and subjugated woman? No. Such a simplistic assessment does not accurately characterize the ‘meanings’ of her fantasy… The vicissitudes of her upbringing and this misogynist culture produced the more negative elements – the undesirable setting and partners and the lack of her own arousal in the fantasy. She couldn’t feel entitled to openly enjoy sexual arousal, which was exactly what was going on with her husband” (location 1685.)

And she concludes,

“Anyway, the point is that pornography is about fantasy and identification with the characters in stories as symbols. It cannot really be understood just on a literal level. And if pornography is suppressed, women will not learn things about themselves and their imaginations that they can learn through experimenting with and reflecting upon their reactions to pornography” (location 1690).

I don’t have much to add to that or to critique here. I’m in agreement.

The rest of the chapter is neat too – she addresses sex worker rights and religious restrictions on masturbation. The only thing is – this chapter may have been stronger if Tiefer had more directly engaged anti-pornography crusaders. I know who she’s talking about, but I think it would have been better if she’d named them anyway.

But the next chapter, Towards a Feminist Sex Therapy, wasn’t as enjoyable. It’s not bad, I just didn’t connect with it. “It’s not you, it’s me.”

I personally do not wish to go through sex therapy, because so far I still haven’t found a sex therapist I can relate to. Mostly I’ve been reading blogs online written by or featuring sex therapists who dole out sex life advice. And most of the time I’m like, “Ehhhhh… not for me… no thx. Pass.” I might start out liking one sex therapist or another. I want to know more about what this or that person has to say.
Then I read further and see flaws in what experts have to say and I can’t reconcile it. I see the sex therapists online or in print say things I find problematic or just plain don’t like, and I get turned off, nitpick and/or refuse to get on board with it.
It doesn’t help that I’ve heard too many stories from other pelvic pain patients who tried sex therapy and had negative experiences with it.
So I’m not into sex therapy right now. “She’s just not that into you!”

Buuuut if you happen to be interested in it, then, in this chapter Tiefer reviews current mainstream sex therapy (or current as of the time of writing,) and talks about how it would be beneficial to inject a healthy dose of feminism into it. It’s a good idea, and basically what I’m trying to do on my own without outside aid. Feminism lets me look at sex, gender, mainstream media, etc differently and asks questions that a not-feminist sex therapist probably wouldn’t think to ask.

The problem is, sometimes it backfires…
In the worst case examples, disagree with one school of thought in feminism or another, and you can be excommunicated. Disagree with an experienced master, and it all goes straight to hell. You get called a bitch or other slurs with a long, charged history in oppression. Or you get kicked out of a feminist clique. Or outed and actively hunted down. Or start cross-feminist blog flamewars.

So what happens if you are assigned to a feminist sex therapist whose school of feminist thought clashes with your own? That therapist is in a position of power over you, after all. Do you disagree and potentially derail the rest of the therapy sessions? Especially if finding a feminist sex therapist was hard to do in the first place. How do you tell your feminist sex therapist “My understanding of feminism is too different from yours for your homework exercises to be of any use to me”?
I guess Tiefer is assuming here that most sex therapy patients are not feminists to begin with, or else they are but are not well educated on even the most basic tenets and local history of the movement. And in many cases, that’s probably true. So I may be overthinking things.
But what if a sex therapist gets someone like me? I already identify as feminist, yet I still struggle with sexual dysfunction. I have a feeling I’d drive any feminist sex therapist I could be assigned to up the wall. Or else the therapist would drive me up the wall and it just wouldn’t work.

So feminism plus sex therapy can sometimes add up to double-edged sword. Not always. But for me, I think I see the potential for stress & needless conflict.

Not only that, but this chapter frustrates me, because of a contradiction buried in the text. At least I’m perceiving it as a contradiction; what do you think?
At one point: Tiefer says, “I fail to see why there can’t be such a thing as ‘sex talent,’ akin to talents for music, athletics, dance, mathematics, humor, or maze-learning directionality – the various other special psychomotor or cognitive gifts we already recognize and celebrate” (location 1829, emphasis mine.)
Hey, wait a minute… Time out, huddle up – isn’t that “Sex talent” statement in direct conflict with the premise of the rest of the book? That is, that sex is not a natural act? How is certain gifted individuals being in possession of sexual talent not conflict with the idea that sexuality is socially & culturally constructed?

Talents can be lost or cultivated but my understanding is that if you have a talent for something, you have a natural knack for it without any previous exposure to training. I have relatives with a natural, seemingly inborn talent for art, spatial analysis, math, etc. Tiefer doesn’t define “Talent” either so I’m forced to double-check my understanding against dictionaries and – well my double-checking backs me up – talent is generally understood to be something natural, innate.

So where does that leave you if  you lack sexual talent? Why do you not call it “Skill” instead, which is something learned? I think that “Talent” is not the best choice of words to use in the context of the rest of the entire book…
And, I prefer to believe that even if you lack talent in some area you want to explore, it’s possible to develop skills from training which will make you just as skilled or even better at some activity than someone with talent. (Especially if someone with talent chooses not to cultivate it.)

Whew, almost done with this post. Did you make it this far?

Last one in this section is, The Capacity for Outrage: Feminism, Humor, and Sex. This chapter contains Tiefer’s thoughts on feminist humor – and she fancies herself quite funny indeed! I still haven’t found her quite as funny as Sady Doyle, but Tiefer is some kind of funny anyway – the kind of funny that compares men with erectile dysfunction to Jackie Gleason bumbling around with bugged-out eyes, for example. In addition to symbolism, Tiefer clearly loves humor.

Feminist humor is a tricky, thin wire to tread upon – “There is no clear line between good “feminist” humor (constructive, political, reformist) and bad “nonfeminist” humor (hostile, women-are-good-men-are-bad, simpleminded) although we can make some meaningful distinctions” (location 2025). What makes a joke funny? What makes a joke political? What makes a political joke inherently feminist?

Well, one of the key elements, is intent.

“As with manslaughter vs. murder, the essential element in deciding whether something is political or not is intention. Is the comedian, cartoonist, or satirist identifying with a movement or struggle, or just ou to get a laugh? Oh, gee, I didn’t mean to upset you by mentioning manslaughter” (location 1875).

Okay I have absolutely no idea what Tiefer meant with that last bit about “Oh, gee,” I can’t quite tell from this bit if she’s being sarcastic there or not but…

But wait a minute – I though that from a feminist point of view, looking at intent alone is not enough. Or, even if you do look at intent plus the other features required to make a feminist joke, you need to look at the consequences. Evil, real consequences spring forth from well-meaning actions, and that includes telling jokes. It might seem funny to whatever group you’re a part of at that moment, but what if, due to various privileges, a joke (or contemporarily, performance art) steamrollers over already marginalized groups you hadn’t thought of?

What happens when you don’t look at consequences?

Well, when you ignore consequences of joking around about FSD, even within a feminist context, you might just get this shit. You get a bunch of partner-blaming, bullying, condescending comments, denial of real medical conditions, and potentially as a result of the above, flagrant misogyny. Perhaps you yourself do not engage in these behaviors, but others with a less sophisticated understanding of feminist humor go there. So in the end, you get a bunch of people who deny that FSD is real, because after all they don’t have it themselves and it’s all a bunch of made up hysterical hooey right? Maybe if your husband would do the dishes once in awhile you’d have enough energy for a sex drive. You just need to get out and think about getting laid and make it happen and it will be better.
No.
When you don’t look at the consequences, you get further stigmatization and you either don’t know, don’t care, don’t believe it, or some combination of the above. And for oppressed groups and individuals, these attitudes can be translated into real-life, dangerous actions.

No. Intent is not enough.

And indeed, this chapter mentions other critical components of what makes feminist humor. But that bit about intent really stood out to me… I think it’s entirely possible to meet all the criteria required make an inherently feminist wisecrack, and still, due to privilege, cause long-term  harm.

Admittedly, the intent discussion takes up only a small part of the rest of the chapter on feminist humor. Much of the rest of the writing here is enjoyable, educational and sometimes amusing. This chapter would be especially useful for a comedian. Seriously, if you want to be any kind of comedian and have any interest in feminist humor, read this chapter. It’s heavy on the theory of humor, but there’s a lot of concrete examples, including pictures, in this chapter. And if you’re a comedian anyway, you’re probably interested in the theory of humor to begin with.
Just remember to think about the consequences of whatever joke you’re telling.

Aaand that takes us to a little over the halfway point of the book. Overall, this third section contained some useful feminist theory and some exploration of the theories in practice, but it wasn’t perfect. (But then, what is?) The next few sections of Sex is not a Natural Act examine medicalization of sexuality (particularly male sexuality) and FSD in greater detail, so these next few chapters should be of particular interest to regular readers. A note though – the 4th section is proving more difficult to analyze & so I may post a follow up after taking a break for awhile, we’ll see how it goes. (I need a better outline of where I want to go with it.)

Let’s read books – Sex is Not a Natural Act, con’t

02/02/2010 at 8:06 pm | Posted in Uncategorized | 4 Comments
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When last we encountered the non-fiction feminist book on sexuality by sexologist by Dr. Leonore Tiefer, Sex is Not a Natural Act and Other Essays, we had just wrapped up reading the first section on my new-to-me (slightly used) Kindle. The book is a real challenge, heavy on academia & theory as it relates to feminism and sexuality. However I’m relieved to say that the chapters in the second section, Popular Writings on the Theme feel less academic, and so it’s a bit more accessible to the general public. Although it contains 6 sub-chapters, Popular Writings on the Theme is shorter and feels shorter than the first section – I didn’t have to use the Kindle’s built-in dictionary feature as often, and I didn’t need to re-read as many passages to absorb their messages. In these essays, Tiefer was writing for a different audience, so she decreased the frequency with which she used postmodernist language.

I also found this second section of the book funnier than the first section, but unfortunately, the humor is not because I found Tiefer’s writing in and of itself funny… No, rather, I often found it funny due to the large gulfs separating Tiefer’s reality and the one in which I live. The grins I made were due to my jaw cynically clenching, my laughter a hoarse, half-choked “Lolsob.”

The first chapter of the second section consists of a series of sexuality columns written for the New York Daily News back in 1980-1981. That’s 30 years ago, waaaay before the internet was readily accessible and long before printed media started to enter its death throes. Most of these essays would probably be helpful to someone who is brand-new to studying sexuality, or who is looking for general sex life advice. Unfortunately, as of the book’s second printing in 2004, these columns are showing their age, and provided very little new material to me. By the time I got around to reading the essays re-printed from the newspaper, I had already encountered elsewhere most of the ideas contained in Tiefer’s old columns. Yes I know sexual spontaneity can be hindrance to a fully enjoyable sexual experience, yes I know that when we (and especially the media) think of “Sex,” our definition is likely very intercourse-centric and that it’s helpful to expand the definition of sex, etc. etc. etc.

But I found myself getting hung up on some changes that have happened since the essays were first printed. For one example, (There’s several other examples I could pick out…) when Tiefer talks about the joys of petting, she states, “It’s joyless and burdensome to cuddle and embrace with someone you neither know well nor want to know better” (Location 875.) But wait, aren’t there cuddle parties nowadays where folks who have never met before can come together and learn to do exactly that? Cuddle parties are designed to be non-sexual, but they may still involve embracing, and that’s not meant to be joyless at all – quite the opposite, from what I understand.

One of the funniest newspaper essays is “Free Love and Free Enterprise,” and the humor comes from how dated the situation described now is. (This essay might be worth burning through your available Google Book preview. You need to be careful with how much you use the GB previews because eventually it will prevent you from going any further. I’ve been able to “Go-around” this limitation by using a second computer or my mobile device, but not everyone has that option…) Tiefer takes the reader through a hypothetical tour of  “A sex show at the New York Coliseum (location 934,) with the goal of showing the reader who stands to profit from the sexual revolution and how… and that includes sex toy retailers, by taking advantage of consumers. Oh, consumers may well benefit, she concedes at the end of the essay, but only as a side-effect.
As I was reading, I thought to myself, “That hypothetical sex convention sounds awesome! How do I get in on that? How do I RSVP for the next show?” Then I remembered – we HAVE a sex & sex toy convention open 24/7 – it’s the internet! Just replace the use of the word “Booth” (used over & over again) with “website/GoodVibes/Babeland/Craigslist.”
Plus, some of the fears Tiefer expressed in this chapter didn’t come to fruition even 30 years later, while others were prescient:

“The next booth moves us into the world of stuff. Under the banner ‘Bare-handed sex is boring,’ we find equipment to enhance the senses and the imagination. Massage oils and flavored lotions lie next to vibrators and dildoes. Alarming displays of bondage equipment are shown along with phony organ enlargers. There are life-size ‘sex partners’ in different colors of plastic” (location 944.)  [It goes on in that manner for a few more paragraphs.]

Now, I did a Google search for the term, “Bare-handed sex is boring,” and as of today, I got nothin’. (Chances are that in a few days one result will link back to this blog entry.) Who would try to sell sex toys under this slogan? Would something so negative even move any stock out the door? I looked up this expression, because in all my sex toy shopping, I have never encountered a sentiment like that from a retailer – have you?
I’ve definitely seen retailers push G-spot toys in particular… but in terms of tactile sensations & calling outright certain sexual activities boring?
Maybe I’m not looking at the right retailers, since I prefer to patronize organizations that market themselves as woman-friendly and sex-positive.
As for the rest – I’m not understanding what message I’m supposed to take away from these passages… am I supposed to be reluctant to explore my sexuality with what’s available to me now because of the motivations behind the companies that sell sexual advice and devices? Am I still doin’ it wrong? Am I supposed to feel sexually inhibited at the conclusion of this essay?

The next few chapters touch upon the symbolism behind sex, sexual acts and sexual medicine, notably Viagra.

Ily already beat me to the chapter on the anthropological approach to kissing, which also explores symbolic kissing in art. For anyone curious as to the contents of this chapter, a slightly different version appears for free at this Kinsey Institute page, so go knock yourselves out. I don’t have much to say on this chapter.

The next chapter talks about how hard it is to have frank & open dialogs about sexuality, even in a sexual relationship. I’m certainly open to talking about how hard it is to frankly talk about sex too, but, I’m still getting tripped up on some of the finer details, particularly the passage about the asexual couple.

Tiefer then goes on to talk about Viagra a a symbol – symbolically, it’s looked at as magic pill that can fix all non-pain sexual problems (Tiefer doesn’t mention anything about sexual pain in this chapter; location 1100.) In reality, the drug isn’t perfect, and it may cause unpleasant, potentially dangerous side effects.

I have no idea what Tiefer was trying to say about Viagra when she then included a Viagra user’s own words followed by her analysis of his situation, because the following passages threw me into rage-rage-rage mode. I think she was trying to make a point about side effects or something:

I am a 37 year old man with erectile problems for 2 years. I have used 50 mg. Viagra 4 times. All of those times have resulted in a very good erection and intercourse. The side effects are headache, upset stomach, stuffy nose, and facial flushing… About 30 mins after taking Viagra I take 2 Tylenol and a Tums and start drinking water. After about 15 mins I take another Tums and use a nasal spray for my stuffiness. I will continue this combination and it will work for me.

This sounds more like a Jackie Gleason routine rather than a romantic evening, but I think it is close to the reality of what life with these drugs will be like… How does his sexual partner feel about the whole drama with the Tums and the nasal spray and the Tylenol? (Location 1109)

Woah, woah woah, waaaait a minute. Hold the phone. Jackie Glea… Jackie…. Gleason? Like, from the Honeymooners?
What the f…
Is that supposed to be a joke? Is this Tiefer’s idea of humor? This essay was given as a lecture in 1999; did Tiefer pause for applause & laughter when she finished reciting this passage?
Since when is Tiefer is the arbiter of what constitutes a romantic evening? Didn’t Tiefer state not a few chapters earlier that actively thinking about and taking steps toward making sex happen is a healthy thing? Is this the same person who said “Some people complain that all this groundwork is too mechanical and time-consuming. Working at sex, they say, defeats the whole purpose, (location 853,) when she debunked the myth of spontaneity? What happened to that?
You know, for someone who claims to want to expand the frank & open dialog of sexuality, Tiefer sure doesn’t make it easy to talk about physical problems and potential treatments for them… that’s a hangup I’m having with her social constructionist approach, it sacrifices biology. I still have the impression that it’s “Either/or” for Tiefer, but not both, and both is what I need.
Okay, someone needs to sit down and explain to me, in great detail, exactly how a guy who uses Viagra in order to maintain an erection for intercourse, and who has found ways to manage the side effects, is like re-enacting a Jackie Gleason comedy routine. I don’t get it.
We don’t have much else to go by as to the background of this person who left himself open & vulnerable by talking about his Viagra use. For all we know, he and his sex partner already incorporated an expanded definition of sex into their lives, and, like myself, decided that that definition was not completely incompatible with occasional intercourse. I say, using Viagra or other prescription drugs, treatments and devices is not necessarily in conflict with a healthy sex life. If using medical treatments leads to a satisfactory sex life, how is that an inherently bad thing?
And if it is an inherently bad thing, then what does that say about me? Is my sex life a big joke to Tiefer? Who am I to her – Lucille Ball? After all, when my partner and I decide we want to try PIV intercourse, I have to go through a  routine involving pelvic floor stretching, lubricant and dilators. Am I supposed to feel embarrassed about doing this in front of my partner? Or about openly talking about it?

There’s not much left of the chapter after that Jackie Gleason bit. Which is good, because I remained in rage-rage-rage mode for the rest of the chapter and was unable to absorb anything more from it. Something about sexual education outside of the  US, I don’t know.

The next chapter, The Opposite of Sex, is another free-to-the-public article originally published online. It consists of Moria Brennan interviewing Dr. Tiefer. It’s part PR for Sex is not a Natural Act, part feminist discussion, part sexuality discussion. The most interesting part of the discussion comes when Brennan asked, “Do you think our understanding of sex also affects our understanding of gender?”:

lt: Gender affirmation is a phenomenally important element in the current construction of sexuality–at least for heterosexuals, who have been the bulk of my clients. Reproduction used to be the essence of gender affirmation for women. And for men it was employment. Now there are fewer and fewer ways of proving gender, and yet it’s as important as it ever was. So how do you prove your gender? You’ve got to be able to have sex–not just any old sex, but coitus. Talking about this in the context of feminism is crucial. It’s men’s investment in a particular kind of masculinity that is fueling Viagra. Part of the work of feminists has been to question accepted notions about masculinity, whereas you could say Viagra is affirming them.

Not being able to have an orgasm is like the epitome of not being normal. It’s the epitome of not being a man or not being a woman. So I would tell them that there are ways to cope with this. Let’s be a man in other ways. No, they couldn’t accept that. To them, this was the proof. (Tiefer, online.)

This isn’t an unfounded idea – I’ve heard this sentiment elsewhere… there’s something familiar about it… I remember; it was that 20/20 segment on vulvodynia. One of the patients interviewed said something about, part of being a woman, is having female parts. Of course, it’s so much more than that. But it’s hard to get that message out, about gender, that it’s more than biology as destiny. So that’s something worth exploring.

The next chapter, the McDonalization of Sex, talks about the standardization (McDonalization – the description on this wiki page matches what’s in the book, so it’s probably a good place to start if you haven’t heard that term before) of the everyone’s sex lives. Although this chapter  is not heavy on academia, I still needed to re-read it a few times before I could understand it… it’s not academic, but it’s difficult because Tiefer jumps around a lot in this chapter. It feels disorganized.

Tiefer  identifies two forces behind the McDonalization of sex – mainstream media and medicine. Ever see very similiar but unrealistic sex lives depicted on TV or hear about it in song? There’s a right way & a wrong way to have sex & be sexy, and if you don’t match what’s in the media, you automatically have a dysfunction. If you’re familiar with this sort of depiction of sex in the media, then that’s an example of McDonaldization.

But in real life I’m not seeing medicine participating in this phenomenon… This is where the gulf between my reality & Tiefer’s is the most pronounced. For example, with regard to how McDonaldization comes from the medical profession, Tiefer claims that,

“There’s another source of the new standards that you may be less aware of. It’s the medical profession, with its new men’s sexual health clinics and the even newer women’s sexual health clinics. These things are popping up all over, almost as fast as new McDonald’s. And they really are fast-fod franchises that specialize in efficiency, predictability, numbers, and control. Everyone who comes in with a sexual complaint gets an expensive workup with genital measurements that seems superscientific. But nine times out of ten, the customer walks out with a prescription for Viagra, and since in the future there will be a dozen or two dozen such sex drugs – for both men and women – if the first one doesn’t work the patient – or is it now merely a customer – will be encouraged to try another and another.” (Location 1270.)

And I’m like… where do I find one of these geometrically growing sexual health clinics? Who are we talking about, what should I be looking for, and how do I get their phone number? Are any of these clinics local? If so, when is their next available appointment? How do I get in on this?
Tiefer doesn’t provide any hard examples of who she’s referring to so I’m left wondering – general OB/GYN practices? Vulvovaginal specialists? (Which, in my experience, are hard to find, especially if you’re not nearby a major metropolitan area…) Planned Parenthood? I typed “Sexual health clinic” into my Google Maps but the nearest results – which are questionable at best – would still take me close to two hours to get to at best.
I guess I’m the odd one out again, because if you consider the vulvovaginal specialist I visited to be a sexual health clinic, I never got a prescription for Viagra (I wonder how I can verify that 9 o ut of 10 statistic claim?) – but I did get a prescription for generic valium (no refills) that’s about $10 a bottle under my insurance plan, and I needed that for general anxiety anyway. At the specialist’s office, we didn’t take genital measurements… although we did use a device to figure out how much pain I was in; does that count? And a hormonal blood test revealed that the birth control pill I was on at the time certainly wasn’t doing me any favors. And I’m still wondering where my two dozen sex drugs are… right now vulvodynia patients, at least, have fairly limited options when it comes to oral medication, and at least two of those options are off-label use anyway. And I’m surprised Tiefer left out the mention of non-drug interventions that sexual health clinic doctors might suggest, including but not limited to diet & exercise, or, perhaps for a very few patients such as myself, surgery.
Indeed, the NVA lists several books of interest that do talk about expanding the definition of sex beyond biology. However the NVA is not in and of itself a sexual health clinic…

Tiefer’s solution is more comprehensive sex education.

The last chapter, Doing the Viagra Tango, is another free-and-available-to-the-public essay (I’m glad I paid only $20 for the Kindle edition of this e-Book instead of $40 for the paperback version! I’m finding several of the essays re-printed elsewhere.) The Tango in the title has two meanings – it’s referring to an old Viagra commercial featuring a couple doing a tango,and Tiefer frequently uses dance as a metaphor for sex. Here, she raises philosophical questions about Viagra – What effects will it have in many areas of life? She raises concerns about negative unintended consequences of Viagra (though I’m not fond of these passages, particularly the line that states that “In the worst-case scenario… The drug eliminates [women's] sense of desirability and sexual efficacy,” (Tiefer, online) because if someone is taking Viagra, then isn’t it just possible that in a heterosexual relationship, the woman may already be feeling like she is not as desirable, due to her partner’s difficulty in maintaining an erection? Tiefer is not interested in exploring ways in which this family of drugs may be helpful, she is mainly concerned its potential dangers.)  She also explores problems in pharmecutical research, problems with insurance in general brought to light by Viagra, and even politics.

And that’s the way the second section of Sex is Not a Natural Act ends. We’re almost 40% of the way done.

At times, passages from Popular Writings on the Theme seem to contradict statements that were made earlier in the book. For example, Tiefer explicitly uses the words “Effective stimulation” in the greater context of the passage that says, regarding sexual activity, “There’s no way but trial and error to identify forms of effective stimulation” (location 907.) But wait, at locations 672 and 684, didn’t Tiefer herself question the value of the terms “Effective stimulation” when used by Masters & Johnson in their Human Sexual Response Cycle study?

One of the biggest questions I’m left with is, if the essays were written today, would they look the same?

I’ve already started chipping away at the 3rd section, which goes into detail about feminism and sexology – it’s a return to academia so I’ve got a ways to go yet before I finish slogging through.

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