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.

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  1. […] dark side of The Pill & prescription birth control. I mentioned something similar to this in part 4 of our continuing series of the sexology book I’m reading – the author of the book left […]

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