"The nature of the body": anatomizing heterogender in sexual medicine.

This paper draws on feminist science studies to critique the construction of women's sexual bodies in contemporary sexual medicine. As "female sexual dysfunction" has become a widely circulated disorder, the intensified medicalization of sexuality has entailed its reduction to physiological processes, and disturbances in these processes are assumed to have potential pharmaceutical solutions. Through an analysis of clinical research in sexual medicine, I demonstrate that the underlying assumptions about genital anatomies, and about sexual "function" and "dysfunction," reflect deeply entrenched cultural notions abut how properly heterosexualized bodies should act, Conclusions suggest that the contributions of recent feminist science studies are helpful in rethinking sexual medicine's deep ontology of sexual difference.

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The nature of the body is the beginning of medical science--Hippocrates

A few summers ago, I was doing research in the archives of the Kinsey Institute at the University of Indiana. Each day, as I walked there from my hotel, I passed the medical school, which had the epigram above carved into the grey stone over the entranceway. Yet as I spent my days researching historical and contemporary works in sexual medicine, precisely the opposite seemed true--that specifying the nature of the body was really the endpoint, not the beginning of medical science. Medical discourses and practices--what Foucault has called the "clinical gaze" (Foucault, 1975)--construct the body and its truths, rather than just "discovering" them. As I will demonstrate in this paper, analysis of the construction of sexual bodies through sexual medicine, which both invents and seeks to remedy pathologies of heterosexuality, provides some fertile ground for pursuing a feminist problematization of the complex discursive nexus of sex/gender/sexuality. The clinical literature on sexual dysfunction provides a fascinating example of a site where cultural expectations of gender (here, as heterosexual performance) seem deeply rooted in the body, resolutely presocial and not open to contestation. With the aid of some conceptual tools from feminist science studies, I hope to contribute to prying the lid off the "black box" of anatomized sexuality, re-opening some of its assumptions to political critique.

Anatomies of difference

Biomedical approaches to sexual dysfunctions invariably begin with a genital anatomy lesson. As Masters and Johnson insisted, "... all of medical science is based on understanding normal anatomy and physiology before meaningful advances can be made in treating abnormalities" (Masters, Johnson et al., 1985, p. 21). Two studies have provided a critical historical reading of sexual anatomies: Alan Petersen's (1998) survey of representations of sex difference in Gray's Anatomy from 1858 to 1995, and Lisa Moore and Adele Clarke's (1995) review of representations of the clitoris in anatomy textbooks from 1900 to 1991. In brief, both of these studies find: (a) the construction of universalized models of sex organs in medical anatomy, enhanced by the development of new visualization techniques, but which always construct the "normal" as "normative"; (b) more emphasis accorded to the penis (as measured by both the number of citations and the space allotted to pictorial and textual representations of each); (c) a consistent emphasis on the "homology" between the penis and the clitoris (1); and (d) differences between the clitoris and the penis characterized by "lack" in the former (especially as it is rendered in medical texts). These features continue to characterize the scientific research that has emerged in the years since these studies. New technologies of visualization--especially the use of Doppler imaging in both animal and human studies--have rendered "normal" genitals and their deviations with increasing precision. The basic homology of the penis and clitoris remains intact--similarities, both anatomic and embryologic, are duly noted, and the clitoris is regularly referred to as an "erectile organ." The ways in which the clitoris differs from the penis continue to be described by the language of "lack"--for example, the "lack" of a subalbugineal layer in the clitoris, and the attendant "absence" of the "rich venous plexus that ... makes the penis rigid" accounts for the fact that the clitoris achieves "tumescence, but not rigidity" during sexual arousal (Berman, Adhikari et al., 2000, p. 24). What distinguishes the most recent scientific research and representation of sexual anatomy however is its context--the definition, diagnosis and treatment of sexual dysfunction. This has introduced, alongside the penis-clitoris homology, an emphasis on complementarity in differentiated sexual anatomies, and renewed attention to the vagina--now discussed in terms of its "functional anatomy" (D'Amati, di Gioia et al., 2003). The argument here is that "modern sexology cannot be truly 'medical' if female sexual anatomy and physiology of female sexual response are unknown" (D'Amati, di Gioia et al., 2003, p. 92; see also Verit, Yeni et al., 2006).

Female sexual dysfunction: anatomizing sexual pleasure, or "it's not in your mind"

One key aspect of the "Viagra phenomenon" (Tiefer, 2006b) is the extent to which a biomedical basis, and the desirability of biomedical solutions, are now assumed for sexual problems. As Leonore Tiefer notes: "the branding of Viagra has succeeded so thoroughly in rationalizing the idea of sexual correction and enhancement through pills that it seems inevitable and only fair that such a product be made available to women" (2006b, p. 287). In the wake of the clinical and market success of Viagra, construction of "female sexual dysfunction" and the search for a "pink Viagra" seems to have captured the imagination of pharmaceutical companies, scientists and the general public.

Female sexual dysfunction (FSD) is a vaguely defined, widely contested disorder, (2) but this has not stopped it from circulating through both the scientific literature and popular media as "age related, progressive and highly prevalent" (Berman & Bassuk, 2002, p. 111). An extraordinary prevalence rate (43%) is widely cited, (3) and repeatedly the clinical literature asserts that FSD is underreported, underdiagnosed and undertreated. These assertions are part of a widespread medicalization of women's sexuality which reconceptualizes sexual problems as primarily physiological. A recent report in Science suggests that two dozen companies now have sexuopharmaceuticals for women in development, hoping to capitalize on this biomedical turn (Enserink, 2005).

In a recent article, Jennifer Berman, a leading figure in the medicalization of female sexual dysfunction, discusses five etiologies of female sexual dysfunction: vasculogenic, neurogenic, hormonal/endocrinological, musculogenic and psychogenic (Berman, 2005). While this, like most reports, gives a brief nod to the role of psychological or interpersonal factors in female sexual dysfunctions, these are cleanly separated from, and largely trumped by, physiological factors which are assumed to be objective and "discoverable." In fact, one of the markers of scientific progress in sexual medicine is assumed to be the extent that the predominant etiology of disorders has moved from psychological to physiological models. This was certainly argued in the case of erectile dysfunction for men, where the fact that "belief in a predominantly emotional etiology" gave way to "identification of the molecular events resulting in an erection" leading to "effective pharmacological treatment." This was taken as a "pre-eminent example of what is achievable by systematic and conscientious application of basic research and clinical observation" (Morales, 1998, p. xv). A similar belief grounds current research on sexual disorders in women. There is an assumption that we just need to know more about the physiology and neurobiochemical nature of female desire and arousal to advance this linear model of scientific progress. Arguing that "the treatment of female sexual dysfunction is gradually evolving as more clinical and basic science studies are dedicated to defining this problem" (Berman & Bassuk, 200, p. 117), the hope is that "future work may provide new insights into the physiology of female sexual arousal and orgasm, suggesting pharmacological treatment options for FSD which act through maximizing biological signaling pathways" (Mayer, Stief et al., 2005, p. 396; see also Mayer, Bauer et al., 2007). (4)

The two etiologies of female sexual dysfunction that have received the most attention are vascular and hormonal/endocrinological, and I will focus on these here.

Vascular etiologies: it's not in your mind, it's in your blood flow

Virtually all of the scientific literature on male sexual dysfunction and the mechanics of erection suggests that one of the potential contributions of progress in this area is a transfer of knowledge to the issue of female sexual dysfunction. After all, the vascular pathways of flow and retention of blood in the penis have been mapped with precision, and erectile dysfunction becomes a simple mechanical problem. Dr. Irwin Goldstein reduced the problem to "creating an erection" which does not "collapse" or "deform" when engaging the "typical resistance posed by the average vagina." As he summarizes it: "The man needs a sufficient axial rigidity so his penis can penetrate through labia, and he has to sustain that in order to have sex. This is a mechanical structure, and mechanical structures follow scientific principles" (cited in Hitt, 2000, p. 36). On the one hand, the penis is conceptualized as a fairly simple hydraulic mechanism, but on the other hand, it is never entirely decontextualized from the act of heterosexual intercourse (i.e., to "have sex" means vaginal penetration with an erect penis).

Subsequent work on women has taken this the new science of the erection as its blueprint, with a focus on vascular flow to the female genitalia, and on the definition of "objective" diagnosis of and potential treatments for female sexual dysfunction. (5) There has been a renewed focus on the vagina, rather than the clitoris, as the female sexual organ of ultimate interest, and the "homology," complementarity, and assumed heterosexuality of male and female genitalia enshrined in the anatomical record are extended here to include diagnostic techniques and treatment possibilities. It is worth quoting one early report at length here as illustrative of the emerging scientific consensus:

The overall field of organic female sexual dysfunction is in great and urgent need of basic laboratory investigation. These last few decades have witnessed the application of modern molecular biologic, biochemical, physiological neuroanatomic, engineering, histopathologic and numerous other methodologies to the study of male erectile dysfunction. Although there has been little previous scientific evaluation of pelvic nerve stimulated vaginal engorgement and clitoral erectile mechanisms, there is no logical reasons why the multiple available technologies cannot be applied and rapidly expand the physiological/pathophysiological knowledge base of female sexual dysfunction. The ultimate objective would be to treat in the future all sexual dysfunctions, male and female, as a "'couple's disease," much like infertility. It is anticipated that once new information on female sexual physiology and pathophysiology is available, future management strategies such as duplex Doppler investigations and pharmacological administration of vasodilators, considered routine in impotent men will emerge in afflicted women (Park, Goldstein et al., 1997).

The two physiological events that have garnered the most attention are "vaginal engorgement" and "clitoral erection," and these have been elaborated in the context of the disorders of "vaginal engorgement and clitoral erectile insufficiency syndromes" (Goldstein and Berman, 1998, emphasis added). It is through these that not only the homology, but the complementarity to the penis, is elaborated. For example, in studies on the erection, a critical role has been identified for nitrous oxide inhibitors that facilitate the smooth muscle relaxation that permits blood to be retained in the penis. As transferred to the mechanisms of female sexual arousal, the presumed function of smooth muscle relaxation is "... to assist with the vaginal function of painless penile penetration" (Park, Goldstein et al., 1997, p. 34). These researchers further attribute "physiologic differences in corporal veno-occlusion in man and woman" to the "different functional roles between the penile and clitoral corpora cavernosa: rigidity and creation of a cylindrical insertion tool in men versus tumescence, support and glans extrusion in women" (Park, Goldstein et al., 1997, p. 35, emphasis added). Thus, the physiological understanding of the penis/clitoris homology is tempered by assumptions about what they are for. While feminists deployed a penis/clitoris homology to claim an independent and autonomous sexuality for women, and to celebrate the clitoris as a site of ecstasy in its own right, contemporary work in sexual anatomy gives it a functional existence in relation to the vagina, which is conceptualized as a receptor for a "cylindrical insertion tool" here, the erect penis (that is, when it's not being used as a birth canal). (6)

The following quotes are taken from one of the most widely cited articles on vasculogenic female sexual dysfunction (Goldstein & Berman, 1998, emphases added):

The vagina is the canal that connects the uterus with the external genital organs; its design is such that it easily accommodates penetration of a rigid penile erection. "(S84-5)

The walls of the vagina consist of three layers.... The muscularis portion is known to be highly infiltrated with smooth muscle and an extensive tree of blood vessels which may swell during intercourse.... The vagina has many rugae or folds that are necessary for the distensibility of the organ; just how elastic it can become is exemplified during childbirth. Still smaller ridges' lend to the fictional tension which exists during intercourse. (S85)

What is the role of the clitoris in sexual arousal? The clitoris may play a major role during sexual activity in that it is not only part of what makes the sexual act enjoyable for the woman but also enhances her response to coitus upon clitoral stimulation. Clitoral stimulation may induce local autonomic and somatic reflexes causing vaginal vasocongestion, engorgement and subsequent transudation, lubricating the introital canal making the sexual act easier, more comfortable and more pleasurable. (S87)

This last quotation is particularly telling. No less than Freud, who viewed the clitoris as being like the "pine shavings" that would ignite the vaginal "log" on the route to mature sexuality (1905/1953, p. 87), they have "discovered" sexual anatomy to be a reflection of normative heterogendered social relations. But whereas we can easily argue with Freud's more explicitly culture-laden route from anatomy to destiny, the very authority of biomedical discourse here--buttressed by the increasingly technologically-sophisticated visualization of vascular pathways--lends an aura of objective truth to their rendering of the coital imperative. It "black-boxes," or enacts discursive closure on what properly sexed bodies are for. Who can argue with visibly mapped processes of vaginal vasocongestion, engorgement and lubrication of the introital canal?

The assumption that these supposedly objective measures of arousal reveal some truth about the body is so powerful that they tend to trump women's subjective experience of arousal. One of the puzzles for medical researchers has been the lack of congruency between objective measures of genital arousal, and reported subjective accounts of arousal (Heiman, 1995; Laan, Everaerd et al., 1995). Jennifer Berman explains this lack of congruency not by casting doubt on the authority of such objective measures, but by suggesting that "... women are often not cognizant of their level of arousal (i.e., the amount of lubrication or genital swelling) (Berman, Berman et al., 1999). Arousal becomes coterminous with measurable genital indicators.

From arousal to desire: it's not in your mind, it's in your hormones

The notable lack of success in finding the "pink Viagra" that would treat female sexual arousal disorder has shifted some of the scientific attention to what is presumed to be an even bigger problem--that of desire. In 2004, as Pfizer terminated its trials of Viagra with women, conceding that they had produced little evidence that it was an effective drug for the treatment of female sexual arousal disorder, another pharmaceutical giant was ramping up its campaign to have androgen deficiency recognized as at the root of women's desire disorders.

Intrinsa, a testosterone patch for women, was the first drug for which approval was sought for the treatment of sexual dysfunction in women. Proctor and Gamble engaged in a massive public and physician education campaign long before its FDA hearing, leaving no doubt that were it approved, it would become widely prescribed to enhance libido. The FDA declined to approve Intrinsa in December of 2004, but Proctor and Gamble remains committed to the product, and numerous articles in clinical journals continue to discuss women's desire deficiencies as potentially treatable with hormones (Bachman, Bancroft et al., 2002; Segraves and Woodard, 2006). However, there is little evidence that lowered testosterone levels are linked in any causal way with decreased sexual desire in women, and trials with testosterone show a large placebo effect (Segraves & Woodard, 2006), making it difficult to sort out what the precursors of desire are. Yet Susan Davis, one of the lead researchers on a trial which showed testosterone levels to be a poor predictor of low desire or sexual satisfaction (Davis, Davidson et al., 2005), still insists that we should treat women with testosterone. As she explained to a Globe and Mail reporter, she continues to use it in her clinical practice, and claims that it will improve her patients' desire "60% of the time." She argues that if women's lack of desire leads to a "mismatch" with their partners, "we'll triple our divorce rates" (Davis, cited in Comeau, 2005). By this logic, it would make as much sense to treat husbands with a daily prescription to dampen their libido. As Germaine Greer argued some time ago with respect to testosterone replacement in women: "If the wife's problem was desire for a husband who was impotent or not interested in her, testosterone would hardly be the drug of choice; if her psychosexual problem was that she lusted for young boys or girls, testosterone would be strictly withheld. The hormone is being given to her for the sake of another" (Greer, 1992, p. 177). Remarkably absent from the androgen-deficiency framework is a serious consideration of women's relationships with others, or the social factors that stimulate or diminish desire. At least early twentieth-century advice acknowledged the social embeddedness of desire, however sexist and naive that advice was. For example, Max Huhner wrote in 1937 that, "The absence of any inclination to sexual intercourse [what he termed frigidity] is normal before puberty and in old age. It may also be considered normal in modestly reared girls up to their marriage" (Huhner, 1937, p. 381). In this account, lack of desire in women, except for those in their childbearing years, is a mark of normality and proper upbringing. While not wishing to endorse this assessment, it at least reflects how closely linked expectations of women's desire are to socially appropriate contexts for its expression. In contemporary work on androgens like testosterone as the biochemical key to desire, the social embeddedness is obscured, though no less relevant. And once decreased libido is socially disembedded and identified as a physiological deficiency, it becomes one more symptom of corporeal dysfunction that one must be vigilant in identifying and treating.

Unpacking the black box: the contribution of feminist science studies

In this paper, I have reviewed the contemporary biologization of women's sexuality as female sexual dysfunction has become a widely circulated disorder, and the manner in which the very social concepts of "sexual function" and "dysfunction" are naturalized through their anatomization. In attempting to disentangle, in both contemporary and historical contexts, the relationship between sexual medicine and heterogendered bodies, a deep ontology of sexual difference becomes visible. However, it is not an ontology of the matter of bodies, but what they are used for, what they do, which foregrounds these bodies as irreducibly social--as heterogendered. Genital anatomies reflect socially derived assumptions about how properly heterogendered bodies should function. These are never inert, but acting bodies, bodies in motion, bodies with "functions" and "dysfunctions." This is the ontological thread that connects feminist theory and sexual science, l think that feminist science studies provide some useful conceptual approaches for a productive rethinking of the ontology of sexual difference.

The sex/gender distinction, conceptualized as a nature/culture distinction, has long been troubling for feminist theory/Tremendously influential was Judith Butler's intervention in collapsing the distinction altogether (Butler, 1990). However, as a number of commentators have noted, Butler perhaps ceded too much power to language. As Karen Barad argues, the question for feminists is not just "how discourse comes to matter" but "how matter comes to matter" (Barad, 1998, p. 108). Both of these analytic strategies tend to leave the fleshy material of the body to the scientists. Relegation of "sex"' to the scientists who "have spent the past thirty years expanding it into arenas we firmly believed to belong to our ally gender" (Fausto-Sterling, 2005, p. 1493) has permitted new forms of biological determinism to flourish. Fausto-Sterling suggests that if we are to stem this "spreading oil spill of sex," we need to reconsider accepted theoretical accounts of sex/gender. Feminist science studies have been in the forefront of doing so, demonstrating that biological bodies materialize gender in dynamic ways. Taking up Barad's challenge to explore "how matter comes to matter," recent work in feminist science studies is prying open the black-box of biological sex difference to find tar more complexity than popularly circulated representations of science admit to (see, e,g., Hird, 2004). In doing so, they help us render more visible the matrix of assumptions about gender and sexuality on which naturalized bodies are constructed.

A key analytic trope builds on work by feminist theorist Donna Haraway. For Haraway such entities as hormones, genes, neurological impulses, organisms and cells are "material-semiotic actors" (Haraway, 1991, p. 200). As she argues, they are neither "discovered" nor "made up," but "congeal from interactions" between human and non-human actants. Haraway refers to this as "corporealization":

.... corporealization is deeply contingent, physical, semiotic, tropic, historical, international. Corporealization involves institutions, narratives, legal structures, power-differentiated human labour, technical practice, analytic apparatus, and much more. The processes "inside" bodies--such as the cascades of action that constitute an organism or that constitute the play of genes and other entities that go to make up a cell--are interactions, not frozen things (Haraway, 1997, p. 142)

As I have suggested in this paper, analysis of how the entities of sexual medicine are formed illustrates that it is corporealization in this sense that produces the "nature of the body." This represents quite a reversal of the Hippocratic maxim. The representation of biological processes of female desire and arousal are representations of these congealed interactions. We need to consider and analyze their production within a shifting coalition of actors including scientists, laboratory technologies, doctors, patients, pharmaceutical industries, clinical publishing venues, mass media and consumers.

There is a long history of feminist critique of the ways in which medical and scientific authorities have constructed women's bodies and sexualities, and of how cultural (rots)beliefs about women have long masqueraded as scientific "fact," circulated and reproduced through laboratory and clinical practices, scientific journals, textbooks and reports in the popular media. Increasingly, however, it is the feminist critics of medicalization who are cast as paternalistic and not having women's best interests at heart, as a feminist rhetoric of equality and choice has been appropriated in the service of pharmaceutical expansion. (8)

Clearly, debates about female sexuality need to move beyond the critique of"medicalization" versus "psycholization"--this is how Irwin Goldstein put it in a recent interview (Enserink, 2005, p. 1579), suggesting that his feminist critics are guilty of the latter. The point of the feminist critique of the medical construction of women's sexuality is not to reassert an "it's all in your head" diagnosis of sexual problems. It is not to claim that sexual problems are not important or don't cause people distress. What is central to our work as feminists is a critique of the simplification and commodification of women's sexuality that medicalization represents. It is critical that we analyze and contest the broader social conditions that have fuelled its acceleration in recent years. As Lenore Tiefer puts it, "aeons of genital research will not create sexual liberation in a world of social inequalities" (Tiefer, 1997, p. 112). To fully understand why this is so requires us to engage with science as a social practice, and to expose as a fiction the assumption that the biomedicalization of women's sexuality is simply a manifestation of a linear model of scientific progress. (9)

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Barbara Marshall

Sociology Trent university

Peterborough, Ontario

Notes

(1.) Moore and Clarke note that the idea of "homology" was deployed to construct a different sort of "truth" about the clitoris in feminist anatomy for example, those constructed in the feminist health movement of the 1970s. Here, the clitoris was not only given centre stage as the sexual organ, but was displayed in a variety of shapes, colours and sizes. However, they found that these feminist reinterpretations seemed to have had little effect on dominant anatomy images, and suggest that what influence they had could be characterized as a backlash of deletion--a "visual clitoridectomy after a few decades of minimal inclusion" (1995, p. 284). The homology of the clitoris and penis was also central to the feminist debunking of the "myth of the vaginal orgasm" (Koedt, 1973). See Gerhard (2000) for a recent treatment of this topic. What is important about the feminist reinterpretations of sexual anatomy is not so much that their "truth" about the body trumped that of mainstream science, but that there was/is an explicit recognition of the "political nature of the anatomized body as turf" (Moore & Clarke, 1995, p. 291).

(2.) Critical accounts of the construction of female sexual dysfunction include Fishman (2004), Hartley (2003), Marshall (2002), Moynihan (2003), Tiefer (2006a).

(3.) The 43% prevalence rate for FSD is derived from the 1992 National Health and Social Life survey, a US study the results of which were published in the Journal of the American Medical Association (Laumann, Paik et al., 1999) after the data were reanalyzed and submitted for publication at Pfizer's behest. The manner in which the presence of a sexual dysfunction was calculated and the resulting prevalence rates have been subject to trenchant criticism--see for example Bancroft et. al. (2003) but this does not seem to have affected the repetition of this figure in both clinical and media sources, where it is often rounded up to "almost 50%."

(4.) This model of scientific progress is also stressed in literature which maps the move from psychological to physiological etiologies for male sexual complaints other than erectile dysfunction. For example, lack of sexual desire in aging men is now constructed as a symptom of androgen deficiency and treated with testosterone; and premature ejaculation is being treated with a variety of selective serotonin reuptake inhibitors. See, for example, Azam (2006), Demers (2003), Donatucci (2006). I call this assumption of a linear model of scientific progress which proceeds from psychological to physiological explanations and results in pharmacological solutions for sexual problems the "pharmaceutical imagination." See Marshall (2009).

(5.) Much of the research on the vasculogenic basis of female sexual dysfunction has been done by those previously working on the vasculogenic basis of erectile dysfunction in men, and is published in the same urological journals, rather than in gynaecological journals. This points to the importance of institutional frameworks in shaping and disseminating research.

(6.) While it would be easy enough to try and explain this framing by reference to adaptive strategies related to some reproductive imperative, this would raise all sorts of questions about what a poor adaptive strategy the differential potential for orgasm through intercourse for men and women is. On this, see Maines (1999, pp. 48-66). The focus of the research on men and women in their post-reproductive years further complicates any sort of argument resting on biological reproduction. For example, a large part of the construction of erectile dysfunction as a disease has required pathologizing what were previously considered "normal" changes in sexual functioning with age, which explicitly rejects the reproductive imperative. See, for example, Marshall and Katz (2006).

(7.) Useful reviews of the various ways in which this distinction has been troubled up by feminists include Adkins (2002), Hird (2004), Marshall (2000).

(8.) This is particularly apparent in popular books such as the Bermans', who couch their endorsement of the biomedicalization of women's sexuality as an extension of equality rights for women. Criticizing previous sexual medicine as sexist for its focus on men, they view the expansion of a physiological model of sexual function to include women as a positive and progressive development (Berman and Berman, 2001).

(9.) Particularly insightful in this respect is Celia Roberts analysis of the history of sex hormones, in which she draws on philosopher of science Michel Serres' theory of 'folded time' to better understand how very old ideas about sexual difference are 'folded into' contemporary scientific discourse and practice (Roberts, 2002; see also Roberts, 2007).