Medical Advances and Human Sexuality: Introduction and Comment.

This issue contains a selection of topics that fall under the classification of medical advances in human sexuality. As you read them, you may ask yourself a variety of questions. Among them, perhaps, are: What is a medical advance? What does this imply about nonmedical advances? And why these and not other topics? I would like to offer some comments on these matters and on the issue itself.

Defining Medical Advance

Advance should indicate something other than change, novelty, or increased activity. Advance implies a direction and a goal. What is the goal of medical treatments for sexual behaviors and conditions that are linked to sexual behaviors? The answer to this question varies depending upon the person/entity responding. If the respondent is a clinician, the goal of a medical advance is a treatment that is safe and helps patients. For a patient, the goal is a safe, effective treatment with few side effects. For a researcher, it is the discovery of a new ingredient, interaction, or pattern, usually with implications for furthering the person's research. The university is interested in developing medical advances that could lead to increased recognition, status, and revenue. For the government, the stated goal is protecting the public and providing regulations accordingly. And for the pharmaceutical companies and other commercial developers of medical products, the goal is research that leads to safe, effective, and profitable products. It should be no surprise then that medical advances are pursued with great vigor as there are potential benefits, both personal and social, that are attractive and compelling. It is also true that these interests are variously competing or collaborating. This presents the opportunity for conflict of interest, even to the extent of endangering any one of these participants but particularly those with fewer resources or less association with a larger organization.

When medical advances are directed at sexuality, a topic more heavily imbued with social, cultural, political, and religious meanings than most medical conditions, we have to be watchful and analytic about the impact of these advances on this complex conduct. Medicine is devoted to defining the abnormal and sexuality is a human condition about which there is erratic agreement as to what is normal.

Not that medicine is new to sexuality. Medical perspectives have had enormous impact in the areas of contraception and HIV/AIDS. More recent and equally controversial is the use of medications, especially oral medications, for sexual dysfunctions. The present JSR issue illustrates this point well and it is clear that several oral and topical medications for sexual dysfunctions are in development. The pharmacological emphasis shifts the focus of intervention, and presumably the influence over the definition and treatment of sexual problems, from the mind to the body, or more specifically to the genitals. The positive side of this change has been new options for patients, increased interest in sexual dysfunction from practitioners, and an infusion of new ideas and funding for researchers. On the negative side of this change is the overt and covert dimishishment of the value of psychosocial conceptualizations, definitions, and treatments for sexual problems. One could argue that prior to the increase of medical interventions, the field had become overly psychosocial in addressing sexuality. Replacing one imbalance with another is unlikely to be an enduring solution.

Implications of Advances for Social Sciences and the Humanities

Currently there is less funding but great interest in furthering the study of sexology from a perspective that pays primary attention to the social, cultural, and historical contextualization of sexual behaviors and responses. Certainly medicine alone will never be able to address the entire picture of what human sexuality is and can be, since the medical reference points are necessarily diagnosis, disorder, disease, and illness (even if their goal is prevention). The role of the nonmedically trained scholar/researcher becomes even more crucial as medicine consumes more of the scientific resources and monopolizes the scientific discourse. My own preference is that research and thinking about human sexuality continue in all relevant disciplines, with ongoing attempts to inform and even influence one another. This is challenging, since the separate disciplines can have rather different languages, goals and definitions of data.

The Topics Within the Present Issue

In developing this issue, JSR editor John DeLamater and I consulted several sex research faculty. We developed a list of areas of importance to human sexuality in which a considerable level of medical research was underway. From that list, a general announcement was posted inviting manuscripts and several authors were directly approached. In a few instances, there was hesitation and/or refusal based on two major factors (other than over-committed and overworked schedules). They deserve mention given JSR's attempt to go beyond psychosocial research. One was the fact that some of the potential contributors preferred to publish in medical journals, of which JSR is not an example. Exposure in JSR, despite it having a good reputation as a sex research journal, was seen to be not particularly helpful to their careers. The second related factor is that JSR was not in Index Medicus. It is abstracted and indexed in a wide array of major social science sources (as printed inside the front cover) but these are less commonly used by the biological sciences. I suggest that these reactions underscore one of the many difficult dilemmas in the field: that truly multidisciplinary approaches to studying sexuality have barriers at many levels including formal dissemination vehicles. The other implication of course is that, if it is so important to be in Index Medicus, in a sense medicine is indeed dominating the flow of information. Index Medicus includes 3,400 titles with articles predominantly on core biomedical subjects and aimed at health professionals as the target audience.

Nevertheless, the majority of contributors, many of whom also do publish in more medical journals, decided to help us bridge this chasm, for which I am grateful and impressed. I think the issue is well represented in the fields of female (Walter Everaerd and Ellen Lann; Claire Yang; Karen Syrjala et al.) and male (David Rowland and Arthur Burnett; Koos Slob et al.; Syrjala et al.) sexual dysfunction. Everaerd and Laan provide a clear summary of developments on the growing frontier of pharmaceutical research on female sexuality. Yang helps us see that the omission of basic neurological knowledge may be as important as the vascular focus that has followed the release of sildenafil by Pfizer, Inc., in 1998. Syrjala provides an analysis of a sexual functioning questionnaire, modified from one already in the literature that is useful for documenting the sexual changes among cancer treatment survivors. Current male sexual dysfunction treatments are thoroughly reviewed by Rowland, hopefully aiding readers who wish to understand the new medication options being researched. Slob offers an uncontrolled study of premature ejaculation using a local anesthetic, a treatment that asks to be compared to the pause/squeeze approach because the clinical concepts behind each approach are diametrically opposed. More pharmacological treatment data is reviewed in John Bradford's critical examination of treatment approaches for paraphilias, with attention to some of the surrounding controversies. Lawrence Severy and Jeffrey Spieler begin to explore the impact of the newer methods of family planning on sexual behavior. The article on cloning by Glenn McGee is included to stimulate JSR readers to begin to think about the implications, if cloning becomes more common, of taking sex even further toward a sex for recreation versus procreation context. Leonore Tiefer's paper analyzes the current cultural forces that present both opportunities and dangers to sexologists, with a clear sense that medicine and sexology do not mix and that sexology, if dominated by a medical perspective, will be compromised.

We are missing an HIV/STD review that eluded us because it appeared difficult to review in any depth in the page limitations required. This is unfortunate because it is in the HIV/AIDS research that great gains in both social science and in medical science have been needed quite desperately. Also missing is genetics, where there is too little research available on sexual behavior and the consequences of genetic code manipulation. It is clear that we are in the midst of a genetics revolution that is likely to entirely change diagnosis and treatment in medicine. One can expect that, over the next decade, genetics will become a more central component of our discussion of the medical aspects of human sexuality.

I am appreciative of the work the authors and reviewers put into this issue as well as the calm and helpful advice of John DeLamater and the JSR staff, Kathy Whitaker, Denise Catalano, and Tara Reihl, who kept the process, authors, and editor moving productively. My hope for this issue is that you will be curious about recent developments in medicine and how they are impacting the field of sexology and the treatment of sexual problems, and that you will critically evaluate its specific and larger meanings for sexual behavior. We need everyone in the field, whether serving on the front lines of family planning clinics or researching signal transduction mechanisms, to be thinking about the concepts, the methods and the policies driving the research upon which we all depend.

Julia R. Heiman Special Issue Editor University of Washington School of Medicine 

Address correspondence to Dr. Julia Heiman, Reproductive and Sexual Medicine Clinic, University of Washington Outpatient Psychiatry Center, 4225 Roosevelt Way, NE, Suite 306, Seattle, WA, 98105; e-mail: [e-mail].