Pleasure, medicalization, and the tyranny of the natural.

Don't ever forget that above everything else, sex is a natural function...and whenever we engage in any natural function in a satisfying way, we experience pleasure. (1)

Sex is popularly assumed to be all about pleasure, but, surprisingly, there's not much about pleasure in contemporary sexological writing.

There is nothing about pleasure dysfunction in the official medical sexual nomenclature, for example, and there's nothing in university-level or medical sexuality texts about the physiological bases of pleasure, cultural differences in pleasure, or the psychological development of pleasure.

In fact, even though most sexologists surely believe that pleasures are absolutely central to the sexual experience, there is very little empirical or theoretical research that focuses on pleasure at all.

An early '90s U. S. probability sample survey conducted in Chicago asked one question about sexual problems experienced in the past 12 months, and about twice as many women (27 to 17 percent, younger to older) as men (10 to six percent) reported that sex was not pleasurable. (2) However, unlike the results about arousal and orgasm, these provocative findings on pleasure were not further analyzed.

This gap would not be a problem if pleasure were a simple matter or automatically inherent in sexual activities, but as a clinician, I can support the Chicago survey's belief that neither sensual nor emotional pleasure is simple or automatic.

As with sexual desire, orgasm, spontaneity, cooperation and comfort the clinician's dirty little undemocratic secret is that the experience of pleasure, as with the other aspects of sexual experience, is distributed along a bell-shaped curve.

But the clinician's impressions remain unsupported by any interesting research into the permutations and vicissitudes of pleasure in sex, Why do we know so little?

I would like to address four reasons for the neglect of the study of pleasure in sexology: conceptual complexity, physiological complexity, political complexity, and the medical model myth of the naturalness of sex.

CONCEPTUAL COMPLEXITY

We use the term "pleasure" in many ways, to state the obvious. (3) Whereas simple sensory pleasures for infants (warm milk, light touching, googly sounds) may be universal, once a psychological and cultural history of conditioning and other learning develops, we no longer all agree as to what is even considered a sensual pleasure.

Only some use the term "pleasure" to describe experiences such as slipping into cool water on a hot day (not those who fear drowning) or tasting a spoonful of a perfect fian (not those who find puddings "yucky") or hearing a Mozart concerto (not those who dislike classical music) or dancing the samba (not those, alas, who are kinesthetically challenged).

As psychocultural history kicks in, experiences get hooked to meanings and pleasures and can move far beyond the sensory or sensorimotor. We speak of the pleasure of a good joke, of seeing an enemy defeated, of sharing a sunset, or of conversation, yet these pleasures are intellectual and emotional.

Pleasure seems to be fundamentally evaluative, although we are usually unaware of the split-second processes involved in appraising an experience or situation before we produce our reaction.

All these processes arise, along with the added ambiguities of what is meant by "sexual," when we think of "sexual pleasure." For some, but not all, a genital component is required for an experience to be sexual. Others would say a kiss, a fantasy, a memory, or an embrace provide sexual pleasure even without genital arousal or awareness. And, of course, genital arousal can occur without pleasure. Sexual pleasures, then, are unique, varied, sensory, intellectual, emotional, and intimately involved with meaning. Research would need a qualitative dimension to capture such complexity.

PHYSIOLOGICAL COMPLEXITY

Periodic upsurges of interest in the physiology of pleasure are related to discoveries in neuroanatomy or neurochemistry, new methods of central nervous system study, or a renewal of research interest in particular (and usually socially disapproved) pleasures such as drug and alcohol use and abuse.

When I was in graduate school, implanting electrodes into animals' brains and observing them press a lever to receive a pulse of electrical current to their "pleasure centers" put the emphasis on the central role of limbic system brain structures.

Later, the focus on "centers" gave way to tracing neuroanatomical circuits identified as "reward pathways." In turn the interest in neuroanatomical circuits shifted to neurochemistry and the role of synaptic transmitter substances, with dopamine identified as the crucial element in the reward circuits.

New noninvasive brain research methods are beginning to allow brain research on human beings in a way never before possible. However, the physiology of what happens when and where continues to be complicated, and when answers change every time new methods develop, the hope of definitive answers recedes.

At the same time as the research on the physiology of pleasure was evolving, a much greater quantity of research focused on the physiology of sexuality. Utilizing neuroanatomical and neurochemical methods to study nervous system components, and also analyzing the role of steroid hormones produced by the reproductive glands, this research has focused on behavior rather than subjective experiences like pleasure or desire.

In animal research on many types of rodents, primates, birds, fish, et cetera, much has been discovered about how various physiological components are involved in species-appropriate mating behaviors. But, as to pleasure, animals are silent and researchers make interpretations.

Physiological sex research on people has necessarily used noninvasive methods and different endpoints, and some surprising results have emerged. This makes us skeptical about research that lacks inquiry into subjects' subjective experiences, and suggests that the connections between physiology and subjectivity will not necessarily be linear.

For example, laboratory research on women has repeatedly demonstrated that, in response to looking at or hearing erotic videos, there is little correlation between (objective) measures of genital arousal and subjective ratings of sexual arousal. (4)

Given the subjective nature of pleasure and its connections to cultural meanings and individual history, it seems plausible that research on the physiological bases or concomitants of sexual pleasure is going to be difficult. There will be no simple answers (for example, "It's endorphins! It's hormones! It's blood flow to the genitalia!") because pleasures are so varied.

The possibilities for pleasure include, for example, the capacity for eroticizing nongenital parts of the body through conditioning and symbolism. As Jeffrey Weeks points out, "In S/M,...the whole body becomes a seat of pleasure, and the cultivation of roles and exotic practices the key to the attainment of pleasure. A degenitalization of sex and of pleasure is taking place in these practices..." (5)

Studying "the" physiology of sexual pleasure is thus bound to fail and should be replaced by smaller projects looking for smaller answers, always taking sexual history and attitudes into account. Again, a qualiltative component seems essential.

POLITICAL COMPLEXITIES

Conceptual and physiological complexities provide challenges, but there would have been more progress in theory and empirical research on sexual pleasure were it not for its perpetually ambiguous moral status.

The pursuit of pleasure, including sexual pleasure, is regarded in Western cultures as (a) dangerous, selfish, amoral, immature, short-sighted, and, at the same time, (b) a legitimate (perhaps the legitimate) aim of human endeavor on earth.

For every Greek myth celebrating the fall from grace of a pursuit of sexual pleasure without regard for honor, duty, or other virtues, there is clearly another myth (or even the underside of the first one) acknowledging the pursuit of sexual pleasure as inevitable and universal.

The consequences of sex for pleasure are even shown in the kind of contemporary U. S. urban myths where the protagonist wakes up in a motel the morning after a night with a stranger with an STD or HIV as punishment for his or her hedonism. (6)

D'Emilio and Freedman, in their book Intimate Matters: A History of Sexuality in America, chronicle this ambivalence about pleasure through American history, with women consistently bearing the larger share of "tension, confusion, and guilt." (7) They argue that "the dominant meaning of sexuality has changed during our history from a primary association with reproduction within families to a primary association with emotional intimacy and physical pleasure for individuals." But they also document in every generation the double standard between women and men who seek sexual pleasure. (8)

In her important edited collection about contemporary feminism and sex, Carole Vance made clear how "the tension between sexual pleasure and sexual danger is a powerful one in women's lives." Women and girls attracted to pleasure must constantly resist charges that they are "bad" ("delinquent," "incorrigible") because pleasure is "selfish, antisocial, and dangerous." These charges are made by social purity groups "protecting" the family who support the exercise of social control over women's desire for pleasure. (9)

Our enduring cultural ambivalence about sexual pleasure is vividly played out in the escalating moral panics about the sexuality of children and youth. Judith Levine's new book on this subject begins provocatively, "In America today, it is nearly impossible to publish a book that says children and teenagers can have sexual pleasure and be safe, too." (10)

THE MEDICAL MODEL

Finally we come to the obstacle to research and theory on pleasure that concerns me the most--the pervasive influence exerted by the model that views sex through the lens of health and disease (the "medical model"), and the roots of this model in what can be called "the myth of sexual naturalism." (11)

The medical model of sex rests on the idea of sex as a natural impulse (or drive) built into people, as it is into non-human animals, by evolutionary forces responsive to the survival-and reproduction-oriented pressures of natural selection.

The sex impulse takes different forms depending on social custom and the vicissitudes of social repression, but at its root it is a biological universe. This perspective is known as "sexual essentialism" and has had a long history in writings about sex, from Darwinians like Havelock Ellis through Kinsey and Masters and Johnson up to the sociobiologists of the present time. (12)

Building on the idea of a natural sexual impulse, the idea of a natural sexual function surfaces, as in Masters' and Johnson's "human sexual response cycle." Their definition of sexual function was a built-in universal excitement-plateauorgasm-resolution cycle expressed in the timely and proper operation of sexual (reproductive) organs such as vaginas and penises.

The idea of the cycle became the norm when the American Psychiatric Association (APA) in 1980 identified sexual "dysfunction" as "inhibition in the appetitive or psychophysiological changes that characterize the complete sexual response cycle" in its diagnostic manual. (13) This language has remained in each subsequent edition and revision of the APA's list of disorders up to the present time.

I have written an extensive critique of the scientific basis of this "human sexual response cycle model" in the references already cited, but suffice it to say here that Masters and Johnson chose research subjects whose orgasmocentric sexual script produced the type of physical cycle they were looking for.

The "human sexual response cycle" was not discovered, in other words, but was scientific window-dressing for Masters' and Johnson's political goal to create gender equality in sex by generalizing to women the male tumescence/detumescence process.

The Masters and Johnson model fit into traditional medical model themes summarized here:

* the idea of an objectively knowable, universal body governed by laws and processes that work independently of social life and culture (for example, penises are the same, whether attached to men in Siberia or Sumatra)

* a separation between mind and body (for example, normal sexual performance is defined as the proper arousal and orgasm behavior of the genital organs regardless of what is going on in the mind)

* the idea that sexuality is a quality or property of an individual

* a focus on biology rather than culture as the defining aspect of sexual experience

* objective lines of demarcation between normal and abnormal sexual function, drawn by scientific (read: politically and morally neutral) experts (14)

Pleasure per se is nowhere to be found in this model or description of sexual (dys)function, since function was merely about the (im)proper performance of physical structures, as with digestion or respiration.

The only subjective aspect of the experience mentioned was pain. "Meaning" was not relevant at all. Meaning had been too much emphasized in earlier psychiatric (read: psychoanalytic) literature, and the new nomenclature represented an effort to put psychiatric approaches to sexuality on a more scientific (read: physiological) basis.

Ironically, a recent modification of the APA's nomenclature for women's sexual dysfunctions, developed in a closed session sponsored by urologists and pharmaceutical companies, (15) introduces the phrase "causing personal distress" into the definitions of the standard sexual disorders (of desire, arousal, and orgasm).

It does not appear, however, that this adds anything about pleasure. Rather, it seems that the reason for the addition of a "personal distress" requirement was to avoid diagnosing a woman as dysfunctional based on her sexual partner's opinion alone.

On the one hand, this is a step away from the universalization of the previous nomenclature--one can have low desire or rare orgasms and not have a dysfunction.

On the other hand, 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" (16) of new pharmacological agents, it seems that considerations of pleasure would only introduce the kind of complexities discussed earlier.

The medical model is too close for comfort to sex as reproduction. The neglect of pleasure and the emphasis on function are tell-tale signs that a one-size-fits-all notion of sexual life and satisfaction is being promoted.

This model, as with all sexual essentialism, seems fundamentally to misunderstand the psychocultural nature of sexual experience. In a misguided effort to support sexual health treatment, norms for sexual life have been created which are at best constricted and neglectful of political realities, and at worst, destructive to the human spirit.

As the global pharmaceutical industry seizes on sexual "problems" as a fertile new market, we must be ever more wary of the consequences of relying on any medical model of sex.

WOMEN'S SEXUAL PROBLEMS

In 2000, I convened a group of feminist social scientists and clinicians to develop a campaign to resist the medicalization of women's sexual problems being promoted by the pharmaceutical industry. (17) (See www.fsd-alert.org) One of our first acts was to release a "manifesto" offering a critique of current trends as well as a new classification system. (18)

Our manifesto, A New View of Women's Sexual Problems, redirected thinking about sexual problems away from a medical model toward a model based on human rights and women-centered research.

We explicitly endorsed the idea of pleasure as a sexual right as stated, for example, in the World Association of Sexology's 1999 Declaration of Sexual Rights, and listed "inhibition of sexual pleasure" as one of women's sexual problems.

Our goal was not to develop a pleasure-centered model of sex but only to challenge the errors of the medical focus that arose without regard to women's sexual realities. It seems obvious that including pleasure is important to any classification system of sexual problems.

CONCLUSION

The neglect of pleasure as a subject in current sexological writing is the legacy of a puritanical and naturalistic sex-as-function, sex-for-reproduction model that is still popular in medicine.

Although few sex researchers or educators would support such a narrow model, our research and educational approaches are still surprisingly silent on the subject of sexual pleasure. This is partly because pleasure, being subjective, is conceptually complex and difficult to study empirically.

Mostly, however, it is because sex researchers and educators still find sexual pleasure a politically dangerous topic. You can unblinkingly apply for a grant to do research on sexual function--but sexual pleasure? You can offer a comprehensive sexuality education lecture on sexual function--but sexual pleasure?

Sexology may be inattentive to sexual pleasure, but the larger culture is busy 24/7 distributing overblown promises of sexual pleasure through consumerist films, popular music, advertising, and, in the latest twist on advertising--the promotion of sexuopharmaceutical drugs like Viagra.

Exaggerated and oversimplified expectations for sexual life require a prepared public, and valid information about sexual plesure must be an important ingredient in future sexuality education. Similarly, higher expectations produce greater disappointment, and future therapeutic systems will need a rich understanding of the operations of pleasure.

If sex researchers and educators neglect the study of sexual pleasure, the public will continue to be vulnerable to shame and disappointment as well as gullible to every new Madison Avenue promise-pusher.

REFERENCES

(1.) W H. Masters and V. E. Johnson, The Pleasure Bond (New York: Bantam Books, 1976), p. 28.

(2.) E. O. Laumann, A. Paik, and R. C. Rosen, "Sexual Dysfunction in the United States, Journal of the. American Medical Association, vol. 281, pp. 537-44.

(3.) M. S. Tepper, Attitudes, Beliefs, and Cognitive Processes that May Impede or Facilitate Sexual Pleasure in People with Spinal Cord Injury (University of Pennsylvania doctoral dissertation in education, 1999).

(4.) E. Laan and W. Everaerd, "Determinants of Female Sexual Arousal: Psychophysiological Theory and Data," Annual Review of Sex Research, vol. 6, pp. 32-76.

(5. J. Weeks, Sexuality and Its Discontents: Meanings, Myths, and Modern Sexualities (London: Routledge & Kegan Paul, 1985).

(6.) M. H. Whatley and E. R. Henken, Did You Hear about the Girl Who? Contemporary Legends, Folklore and Human Sexuality (New York: NYU Pres, 2001).

(7.) J. D'Emilio and E. B. Freedman, Intimate Matters: A History of Sexuality in America (New York: Harper & Row, 1988), p. 176.

(8.) Ibid., p. xv.

(9.) C. S. Vance, editor, Pleasure and Danger: Exploring Female Sexuality (Boston: Routledge and Kegan Paul, 1984), p. 1.

(10.) J. Levine, Harmful to Minors: The Perils of Protecting Children from Sex (Minneapolis: University of Minnesota Press, 2002), p. xix.

(11.) L. Tiefer, "Women's Sexuality: Not a Matter of Health," in A. J. Dan, editor, Reframing Women's Health: Multidisciplinary Research and Practice (Thousand Oaks: Sage Publications, 1994). pp. 151-62; L. Tiefer, Sex Is Not a Natural Act, and Other Essays (Boulder, GO: Westview Press, 1995); L. Tiefer, "Sexual Biology and the Symbolism of the Natural," in M. M. Gergen and S. N. Davis, editors, Toward a New Psychology of Gender: A Reader (New York: Routledge, 1997), pp. 363-74; L. Tiefer, "Challenging Sexual Naturalism, the Shibboleth of Sex Research and Popular Sxology," in D. Bernstein, editor, Gender and Motivation, Current Theory and Research in Motivation, volume 45 (Lincoln: University of Nebraska Pres, 1999), pp. 143-72.

(12.) J. Weeks, Sexuality and Its Discontents, 1985.

(13.) American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) (Washington, DC, 1980).

(14.) L. Tiefer, "The Medicalization of Sexuality: Conceptual, Normative, and Professional Issues," Annual Review of Sex Research, vol. 7, pp. 252-82.

(15.) R. Basson, J. Berman, A. Burnett, L. Derogatis, D. Ferguson, J. Fourcroy, I. Goldstein, A. Grazziottin, J. Heiman, E. Laan, S. Leiblum, H. Padma-Nathan, R. Rosen, K. Segraves, R. T. Segraves, R. Shabsigh, M. Sipski, M. Wagner, and B. Whipple, "Report on the International Consensus Development Conference on Female Sexual Dyfsunction: Definitions and Classifications," Journal of Urology, vol. 163, pp. 888-93.

(16.) Ibid.

(17.) L. Tiefer, "Arriving at a 'New View' of Women's Sexual Problems: Background, Theory, and Activism," in L. Kasehak, and L. Tiefer, editors, A New View of Women's Sexual Problems (Binghamton, NY: Haworth Press, 2002), pp. 63-98.

(18.) L. Tiefer, M. Hall, and C. Tavris, "Beyond Dysfunction: A New View of Women's Sexual Problems," Journal of Sex and Marital Therapy, vol. 28, no. 5, pp. 225-32; L. Kaschak and L. Tiefer, Editors, A New View of Women's Sexual Problems (Binghamton, NY: Haworth Press, 2002).