A New View of Women's Sexual Problems: Why New? Why Now?

Journal of Sex Research,  May, 2001  by Leonore Tiefer

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The Federal Drug Administration's (FDA) March, 1998 approval of sildenafil citrate, an oral drug to treat "erectile dysfunction" (the first approval went to Pfizer, Inc., which is using the brand name Viagra), capped a 15-year process of promoting a medical classification system, market, and scientific literature for men's sexual problems, a process I have chronicled for some time as "the medicalization of male sexuality" (Tiefer, 1986, 1994, 1995, 1996, 1999, 2000a). The process explicitly selected particular elements of men's sexual and reproductive potential as medically normal (just-right erection, just-right ejaculation and orgasm, just-right desire frequency and object), and promoted them as natural, universal, and sufficient for proper sexual conduct and experience. That this has happened during a period of rapid change in gender roles means that the medicalization of male sexuality also functions as part of the contemporary reshaping of masculinity (Seidler, 1997).

Beginning in the early 1990s, and escalating after the approval of sildenafil, urologists, pharmaceutical industry representatives, and some sexologists began to focus on women's sexual problems with a similar medical paradigm emphasizing physical causes, physical aspects of sexual experience, and physiological assessments and treatments for women's sexual problems (Basson et al., 2000; Berman & Berman, 2001; Berman, Berman, & Goldstein, 1999; Rosen & O'Leary, 1998; Tiefer, in press). This initiative has produced widespread media attention (e.g., Hitt, 2000; Kolata, 1998; Leland, 2000; Martindale, 2001; Rosner, 2001) and seems likely to create an atmosphere of medicalized thinking about women's sexuality, and a market for medical products, as happened for men (Tiefer, 2000b).

Only within academic areas of history, sociology, cultural studies, and science and technology studies has the triumph of a medical view of sexuality been seen as an active process, promoted by groups with particular political and socioeconomic interests, and not simply as an inevitable outgrowth of scientific and medical discoveries (e.g., Boyle, 1994; Irvine, 1990; Jackson & Scott, 1997; Mamo & Fishman, in press; McLaren, 1999). Scholars in those academic areas, as well as feminist and gay/lesbian political writers, have examined the disdvantages as well as the advantages of this dominant medical paradigm, and have argued that nonmedical frameworks for sexuality theory and research that privilege sexual rights, diverse cultural meanings, and humanistic therapies are equally valid (Kleinplatz, 2001; Parker, Barbosa, & Aggleton, 2000; Parker & Gagnon, 1995; Plummer, 1995; Weeks, 1985). As part of this movement, the "new view" of women's sexual problems (see Appendix) advocates for sexuality theory, research, education, and practice that are meaning-centered rather than function-centered, consciously political rather than passively apolitical, and grounded in humanistic rather than in biological foundations (Connell & Dowsett, 1992; Evans, 1993; Weeks, 1995).

PROBLEMS WITH MEDICALIZATION

The hallmarks of the medical model include mind-body compartmentalization, generalizations about human function and experience, and a focus on the individual, all of which create a universalized, function-focused sexuality in which physiology dictates sexual conduct (Boyle, 1994; Tiefer, 1995, 1996, 1999). This model has probably allowed at least some sex education and research in a culture still paralyzed by its history of prudery and hypocrisy in which embarrassment and value conflicts about sex remain pervasive (Money, 1985; Reiss, 1990). Medicalization offers a vocabulary of biological innocence--the kneebone is connected to the anklebone--to purge the lubriciousness from any discussion of sexuality, and there may have been advantages to that in the past.

But in the twenty-first century, sexual images permeate ads, films, television, and the internet; sexual issues are high on the global public health agenda; people travel, emigrate, and date partners with different sexual values; celebrities and politicians offer a kaleidoscope of messages about sex and gender; ordinary people are living longer, more vigorous lives--and both public and professionals need scientific and clinical models of sexuality and sexual problems to help them cope. The prevailing medical model and nomenclature, deriving from the work of Masters and Johnson (1966, 1970) and Kaplan (1974, 1977, 1979), and codified in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual (1980, 1987, 1994), are inadequate to fill this tall order. They contain too many mistaken claims (errors of commission) and leave too much out (errors of omission) (Boyle, 1994; Tiefer, 1992, in press).

Recently, a group organized by urologists and sponsored by the pharmaceutical industry met in closed session to create new "consensus statement" nomenclature for women's sexual problems (Basson et al., 2000). Despite acknowledging that many areas of women's sexual experience and problems are poorly understood and difficult to assess, the document deviated very little from the prevailing APA norms of desire for sexual activity, attained and sustained arousal, and orgasm, and ended by strongly encouraging "clinical trials of vasoactive agents, steroidal therapies," and "psychosexual therapy alone or in combination with pharmacological treatment" (Basson et al., 2000, p. 891). That doesn't seem to acknowledge massive cultural changes in sexuality at all.