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Sex therapy in the age of Viagra: "money can't buy me love".

"[Q]uestions of sexuality are inevitably, inescapably, political questions." (1)

"What men do not observe because their intellect prevents them from seeing would fill many books." (2)

INTRODUCTION

Sex therapy made news recently: A panel of the federal Food and Drug Administration voted against approval of flibanserin, a medication that claims to treat "sexual desire disorder" in women, prompting the manufacturer to halt development, while still continuing clinical trials. (3) Hailed by some as a "pink pill" that would

improve women's sex lives just as the now ubiquitous "blue pill," Viagra, had promised for men, (4) the development of flibanserin struck others as profoundly inimical to women's interests and as a profit-motivated manipulation of the goal of gender equality. (5) Although the two drugs operate in very different ways, (6) their link in the public discourse provides a telling glimpse of not only the contemporary approach to sex therapy but also current sexual norms, ideals, and fantasies. (7)

Our examination of changes in sex therapy over the past sixty years illuminates how a promise of liberating transformation, including new understandings of "sex" and new sexual expectations and practices for women, failed to materialize. In recounting specifically how Viagra emerged from earlier versions of sex therapy, we expose how androcentric notions of "sex" as intercourse have both resisted change and upheld patriarchal authority, frustrating the earlier promise. Studying sex therapy illuminates a society's fantasies of healthy and adequate sexuality and provides insight into the tension between love and money, (8) the purported divide between private and public, and the reproduction and persistence of gender hierarchy in America, notwithstanding several decades of equality-minded law reforms and feminist developments.

Even more, sex therapy as a case study can help make visible the ethos of two contrasting ages. Our analysis of the triumph of Viagra and its implications for sexual relationships turns out to have much in common with critiques of today's prevailing neoliberal ideology and its implications for increasingly oppressive national and global politics. (9) While many would consider the study of sexual problems to focus on personal life, we agree with Jeffrey Weeks's observation, in our first epigraph, that questions about sexuality are always wider political questions. (10) Building on Weeks's insights, we also make the case that personal fantasy inspires and legitimates public priorities. Our analysis unfolds in two parts. Part I considers the birth of William Masters and Virginia Johnson's theory of the human sexual response cycle in the 1960s, a theory which included both an innovative view of female sexuality and identification of what the researchers called "sexual dysfunction," a term they coined. (11) An account of this pathbreaking work unfolds in a recent book by Thomas Maier, Masters of Sex: The Life and Times of William Masters and Virginia Johnson, The Couple Who Taught America How to Love, which we use as our point of departure. (12) Part II analyzes the most popular form of sex therapy today not only as an artifact of the paradigm shift initiated by Masters and Johnson's construction of sexual dysfunction but also as an erasure of the researchers' findings about female sexuality. In this section, we use multiple lenses--first, culture, law, and public policy and, second, notions of fantasy as developed in psychoanalytic literature--to contextualize and interpret Masters and Johnson's work and subsequent developments. This examination shows how innovations that Masters and Johnson advanced embodied what became a clash of standpoints, which ultimately evolved into contradictory sex therapies, each erected on a contrasting (and we think gendered) version of what constitutes "good" heterosex. Although their approach did not envision sex therapy as merely prescribing a pill, Viagra's preeminence today has nevertheless become one of their most significant legacies, even if rarely understood as such. Finally, we weave these strands together to show an emerging pattern in the way sex therapy and the search for sexual improvement continue to devolve, eroding the aspirations that Masters and Johnson's work had inspired. This pattern not only reveals a continuing struggle over gendered meanings of sex, intimacy, and power. It also naturalizes and fortifies the individualism, domination, exploitation, and moral anesthesia that critics see valorized in our current neoliberal moment. (13)

I. PARADIGM SHIFTS IN THE SCIENCE OF SEX

A. Masters and Johnson's Story

Maier's book about "the couple who taught America how to love" details for the first time the major role Virginia Johnson played in the founding of contemporary sex therapy, suggests that the gender of the researcher can make a significant difference in the outcomes of scientific inquiries, and sees Johnson's impact as a sign of increasingly feminist times. (14) Maier credits Johnson with momentous contributions to what are usually regarded as primarily Masters's two pioneering accomplishments. (15) In the first project, sex research, Masters set out to break new ground beyond Alfred Kinsey's collection of survey data about sex by conducting direct clinical observation, including measurement and documentation of subjects' physiological responses during sexual activity. (16) The second project, sex therapy, grew out of the first and entailed interventions designed specifically to address the understanding of "sexual dysfunction" (17) that emerged from the research findings.

According to Maier, Johnson played a formative role in both projects and in the widely read publications they produced, Human Sexual Response in 1966 and Human Sexual Inadequacy in 1970. (18) Johnson, who began her work with Masters in a secretarial role, ultimately became his full-fledged partner in both projects and later his wife. (19) Without Johnson's winning social skills and sexual savvy, there may well have been only limited research results. Johnson successfully recruited ample research subjects by persuading graduate students, nurses, and doctors' wives to volunteer in the interest of advancing sexual knowledge for women; (20) she trained volunteers how to perform sex for clinical observation; (21) she designed the treatment for sexual dysfunction as dual or conjoint (that is, for couples by pairs of therapists); (22) she made sure the desires, pleasure, and voices of female clients were heard and respected by male partners and researchers; (23) she created therapeutic exercises like "sensate focus" to counteract clients' sexual inhibitions and to establish a foundation for deeper intimacy and communication; (24) and, finally, she recruited and trained "surrogates" to work with male patients who wanted to participate in Masters and Johnson's research and therapy but lacked regular partners. (25)

Maier explains that Johnson saw dual-sex therapy as a natural repetition of the model of dual-sex research Masters first hired her to develop with him. (26) Just as the study's subjects were made secure by having same-sex researchers to lead them through the roles they needed to play in the clinic, so, too, sexually "dysfunctional" clients, all presumably heterosexual, were given confidence by having same-sex therapists provide greater empathy for their gendered standpoints. (27) Further, by having a pair of therapists, the pair of clients had both sex-positive models to emulate and protection from the possibility of sexual enmeshment with therapists, a dangerous occupational hazard. (28) Johnson frequently inserted into the clinic procedures a voice of concern and nurturance and often used her personal knowledge of female sexuality to revise Masters's androcentric assumptions. (20)

Although Masters and Johnson expressed hope that their revolutionary methods would eradicate sexual dysfunction "in the next decade," (30) their manifest influence withered before the century was over. Today, Washington University, where Masters and Johnson started their studies, omits the pair from its official history. (31) Many couples therapists today find sex "too private" a realm to enter with troubled clients seeking relationship repair. (32) And the pharmaceutical industry has co-opted sexual dysfunction as a medical problem unconnected to interpersonal issues and so requiring no more than a prescription or an order online for a pill. Maier's story ends with the demise of Masters and Johnson's twenty-one-year marriage and twenty-five-year intellectual and business partnerships, (33) but it neither parses the cultural meanings of the market share that their dual-sex therapeutic model ultimately lost to sildenafil citrate treatment (sold as Viagra and other popular brands) in the late 1990s (34) nor theorizes the present controversy surrounding flibanserin, the unapproved and, for now, discontinued drug created to ameliorate women's "hypoactive sexual desire disorder." (35) We focus on these gaps, especially emphasizing certain contextual elements that we think make sex therapy a vital topic for scholarly investigation in general and feminist analysis in particular.

B. Masters and Johnson's Contributions

The most radical aspect of Masters and Johnson's findings might have created a Copernican-like revolution in Western sexual history. The researchers themselves mistakenly assumed the significance of the results of analyzing over ten thousand filmed observations of coitus and masturbation lay in their "discovery" of the four-phase human sexual response cycle, which, when gone awry, needed only brief therapy to re-establish itself. (36) In a far more influential finding, however, they identified female sexual response as clitorally, not vaginally, triggered, disproving Freud's theories of the vaginal orgasm while indicating the degree to which conventional heterosexual technique denied women the stimulation they needed to achieve sexual climax. (37) As if finding out the penis did little for women's vaginas was not radical enough, Masters and Johnson also found that female sexual response was significantly more robust and abundant than male sexual capacity, facts obscured by previous generations of androcentric cultural assumptions, sexual myths, and bedroom practices. (38)

Beyond revising long held views of sex, Masters and Johnson's findings had momentous implications for sex therapy, which has a history stretching back to Hippocrates and ancient Greece. The St. Louis researchers transformed thinking about sexual difficulties when they exposed how sources of sexual disruption were not only simpler than then believed, but also easily treatable with short-term educational and behavioral interventions. (39)

Throughout most of the twentieth century, sexual problems had been understood within a psychoanalytic framework, which assumed that anxieties causing sexual disturbances derive from unconscious conflict stemming from an individual's childhood repressions. (40) Psychoanalytic treatment required patients to undergo years of analysis, yet it yielded a success rate of less than 20 percent. (41) Following Masters and Johnson's report in Human Sexual Inadequacy that brief behavioral therapy and techniques they used to treat what they called "sexual dysfunction" attained 80 percent success rates, (42) a plethora of sex therapists rushed into business. Over five thousand sex therapy clinics sprang up across the nation, and twelve academic sex therapy journals popped into circulation. (43) A paradigm shift had occurred. (44)

Masters and Johnson's success sparked interest in continuing sex research and in expanding therapeutic services. Counselors, physicians, and couples therapists gained specialized training at Masters and Johnson's clinic and started helping married couples particularly see more clearly what was working and what was not working in their sex lives and relationships in general. (45) Their sex therapy, positioned as an answer to rising divorce rates, became a revolution that gained worldwide prominence, symbolized by pictures of Masters and Johnson on Time Magazine's May 25, 1970 cover, which announced a new "sex education for adults." (46) When the pharmaceutical industry, keenly aware of public interest in Masters and Johnson's work on sexual dysfunction, discovered that a medication they were testing as a treatment for angina resulted in erections, they opportunistically decided to launch the drug as a pharmaceutical sex therapy that could appeal to men generally, not just to those presenting with a specific medical problem. (47) Masters and Johnson's "new sex therapy" (48) paradoxically led to divergent therapeutic models, including the development, marketing, and medical prescription of Viagra. This pharmaceutical model has become the site of sex therapy's current frontier, shown by work on a new drug designed to boost female libido, (49) while the numbers of sex therapists who treat sexual dysfunction conjointly continues to dwindle.

II. CONTEXTUALIZING CHANGES IN MODERN SEX THERAPY

In an interview for a televised retrospective on the achievements of Masters and Johnson, Virginia Johnson reflected: "We existed because of the times, not in spite of them." (50) The social and regulatory environment in the years from 1957 (when Masters began his research) to the early 1970s (when the impact of Human Sexual Inadequacy peaked) did, in fact, create an ideal climate for Masters and Johnson's iconoclastic studies and publications. Nonetheless, Johnson's statement is incomplete to the extent it fails to credit the agency that Masters and Johnson exerted, which shaped culture, law, gender, and sexuality, just as these forces all shaped the researchers' work. (51) Similarly, Viagra's present market dominance also both reflects and helps construct a new cultural moment. We consider each of these eras in turn.

Our temporal lens provides one tool for understanding how sex therapy has changed and why. But, without more, this linear, historical approach risks overlooking more enduring and cyclical considerations that cut across the years. Accordingly, after situating Masters and Johnson's work and the aftermath in their respective eras, "then" and "now," we examine the dynamic role of fantasy in what Thomas Laqueur calls "the longue duree" of sexuality. (52) This additional frame enables us to tell a new story about Masters and Johnson's contributions to the creation of contemporary sex therapy and to interpret the preeminent place of Viagra and other pharmaceutical aids to sex in our culture today.

A. Two Cultural Moments

1. Then

Several distinct features of the era when Masters and Johnson made and announced their discoveries stand out. First, when Masters launched his research project at Washington University in 1957, Ethan Shepley was Chancellor. Although a member of the "establishment" and power elite who was heading an institution located in a particularly conservative city in the Midwest, Shepley embraced a strong commitment to academic freedom. (13) The role of Shepley cannot be overstated. He was fully aware of the controversy that Masters's project (initially using sex workers as subjects) could likely ignite, as Maier's book makes clear. (54) Although Shepley's particular milieu might make his support for the project appear unexpectedly bold, the legal landscape had become especially congenial. Academic freedom was enjoying a heady ascendancy during this time, with growing appreciation by the United States Supreme Court of the First Amendment values that McCarthyism had jeopardized in the 1950s. (55) Supporting the quest for expanded sexual knowledge, precisely because of the conventions that the research would challenge, provided a powerful way to demonstrate that investigation and discovery are inherently worthy pursuits, that educational institutions must remain above the common social and political fray, and, perhaps, that sex--like all other aspects of human experience--constitutes an appropriate focus for scientific enterprise.

In addition, Masters's interest in exploring new frontiers of knowledge, conquering ignorance through science, and taming the wild and mysterious forces of sexuality by subjecting them to measurement and analysis shared a number of features with the contemporaneous "space race." The Soviet Union had launched Sputnik the same year that Masters started his research, and four years later President Kennedy set as the United States' goal putting a "man on the moon" before the end of the decade. (56)

Despite the unorthodox nature of Masters's focus, there was little reason at the outset to suspect he would challenge the prevailing androcentric understanding of sex. True, Masters's treatment of ob-gyn patients encountering fertility problems might suggest special concern for women, and his initial studies with sex workers indicated that he regarded women as indispensable to his investigation, but his plan to conquer scientific ignorance about sex made no promises (or threats) about altering the primacy of the male role. (57) In fact, we believe--consistent with Maier's account--that the project acquired its feminist dimension only after Virginia Johnson signed on.

Again, however, the timing could not have been more propitious, given the study's ultimate discovery of women's amazing sexual capabilities. A scant four years before Masters and Johnson started their research into the physiology of sex, Simone de Beauvoir had published her English translation of The Second Sex, which made clear that women are "made, not born." (58) The sexual revolution received a boost with the FDA's approval of the birth control pill in 1960, (59) the National Organization for Women formed in 1966, (60) and Eugene McCarthy introduced the Equal Rights Amendment in the United States Senate in 1967. (61)

While de Beauvoir had opened inquiry into how women's sexuality was socially constructed to serve the interests of patriarchy, Germaine Greer added to this analysis with her complaint about women's sexual oppression in The Female Eunuch:
      The title is an indication of the problem.... Women have
   somehow been separated from their libido, from their faculty
   of desire, from their sexuality. They've become suspicious
   about it. (62)

      Like beasts, for example, who are castrated in farming in
   order to serve their master's ulterior motives--to be fattened or
   be made docile--women have been cut off from their capacity
   for action. It's a process that sacrifices vigor for delicacy and
   succulence, and one that's got to be changed. (63)


Other texts of the period illuminated the reciprocal effects of subjugation and women's sexuality. Betty Friedan's The Feminine Mystique suggested women's dissatisfaction was tied to women's social marginalization. (64) Shulamith Firestone's The Dialectic of Sex linked women's secondary status with her reproductive duties. (65) Kate Millett's Sexual Politics examined the sexism in canonical literary works written by men, who equated the phallus and the pen. (66) Robin Morgan's Sisterhood is Powerful offered essays like It Hurts to Be Alive and Obsolete: The Ageing Woman, Media Images 2: Body Odor and Social Order, The Politics of Orgasm, The Hooker, and Notes of a Radical Lesbian, which challenged conventional notions of sexuality. (67) Feminist criticism identifying sexuality as a primary site of women's oppression and possible empowerment both contributed to and gained from Masters and Johnson's discovery of female sexual prowess, their rejection of the Freudian ideal of the vaginal orgasm, and their scientific celebration of the expanded role of the clitoris. (68)

Simultaneously, Masters and Johnson's therapeutic interventions, such as sensate focus exercises, (69) resonated with the ethic of care, later theorized by Carol Gilligan, which has become a hallmark of cultural feminism. (70) No doubt, Masters and Johnson could not have even conceptualized their dual-sex therapy without the contributions of feminism to their times, a connection that Maier acknowledges. (71)

Transformative legal developments also marked this cultural moment, which saw the dawn of constitutionally protected reproductive rights and gender equality, as well as responses to the feminist critique of traditional family law. During the late 1960s and early 1970s, the Supreme Court ruled that the constitutional fight to privacy includes the freedom to decide "whether to bear or beget a child" without undue government interference and without regard to marital status. (72) Relying on the Due Process Clause of the Fourteenth Amendment, the Court extended privacy's reach by holding that the right to make reproductive choices encompasses abortion decisions, at least within certain limits.(73) Although the Court's "privacy" language might have obscured the gendered significance of these opinions, some of the Court's language acknowledged the uniquely onerous burdens that birth control restrictions and abortion prohibitions imposed on women (74)--points that commentators were quick to reinforce. (75) In any event, such rulings gave women access to sexual intercourse without the risk of reproductive consequences.

During the same period, the Supreme Court initiated a string of rulings under the Fourteenth Amendment's Equal Protection Clause that, cumulatively, claimed to overturn all classifications reflecting gender-based stereotypes--even stereotypes that enjoy some empirical support. (76) These cases encompassed not only sex discrimination in the so-called public sphere, such as eligibility for jury duty (77) and for admission to state-operated nursing schools, (78) but also in the supposedly private realm of the family, which had previously been governed by a strict code of gender roles. (79)

Accordingly, feminists, who had identified a surfeit of inequities in family law (from the allocation of property at divorce (80) to the of domestic violence (81)), succeeded in winning several tolerance reforms. The gradual gender-neutralization of family law that followed left the legal meaning of "husband" and "wife" with little substantive content--although, of course, in many individual (private) family units, men and women continued to play their traditional roles, with no shortage of societal encouragement. (82)

Critics of the would-be public/private divide purporting to define family law's "separate sphere" (83) took aim from many vantage points. For example, some feminists emphasized the illusory nature of the split, given the role of government in drawing such legal lines in the first place. (84) Others condemned the purported privacy of the family as a shield for domestic violence (85) or a rationalization for leaving carework and other domestic services uncompensated and thus undervalued. (86) Not surprisingly, many noted that when the legal issues concern money--such as welfare dollars--privacy doctrine does not protect individual decisionmaking or intimate conduct, but instead constrains it. (87)

Of course, one might not only see the regulatory environment as especially conducive to Masters and Johnson's liberatory discoveries for women, but also regard these researchers' findings as altering the perspectives of legislators, judges, and advocates who were reframing and reforming laws governing family, reproduction, and gender. Masters and Johnson's work brought sex "out of the closet," making it a popular topic of public conversation, (88) in turn challenging the habitual equation of sex with privacy. (89) Further, public discussion of sex diminishes the possibility that the status quo, including the privilege accorded to male pleasure, must continue unquestioned. (90)

2. Now

Consistent with the Camelot imagery popular in the 1960s, (91) Masters and Johnson's "shining moment" did not endure. Masters's work, especially after his affiliation with Johnson, began to fall out of favor at Washington University's School of Medicine, even while the two garnered acclaim throughout the world. Johnson, of course, was not only a woman whose collaboration with Masters threatened gender hierarchy, but--given that she had never earned a college degree--her co-equal partnership with Masters also challenged academic hierarchy, an artifact of male privilege. (92) Thus, their teamwork itself might be read to have feminist overtones, although other interpretations are also plausible. (93)

In any event, the end of the pair's work at Washington University came in 1963, after a presentation of films documenting physical changes in research subjects during sexual intercourse in the laboratory had horrified colleagues. (94) Signaling rejection of Masters and Johnson's work, Masters's colleagues gossiped that they recognized Johnson's naked body in the film. (95) Associates flatly and convincingly denied Johnson ever participated as a research subject, but the censorious responses of the Washington University School of Medicine's Department of Obstetrics and Gynecology to what Masters regarded as visionary proved deflating and presaged further resistance. (96) That Johnson became the target of the ridicule crystallized the discomfort that Masters's collaboration with his female subordinate had stirred all along. Masters and Johnson moved their project off campus and enlarged their quarters by taking over an entire floor of a stylish apartment building. (97) Although perhaps isolated and local, this move could be read to signal a more tectonic change.

Whether or not Masters and Johnson's departure from Washington University had a larger meaning, clearly academic medicine and scientific research look different today compared to when Masters began his work. We use 1998, the year when the FDA approved Viagra, (98) to mark the completed transition to this new era, characterized by the ascent of values that scholars have identified as neoliberal, including individualism, independence, rationality, free-market economics, and anti-moralism. (99)

First, most importantly, money now looms much larger. Today, educational institutions are conceptualized as part of a market system--and not in the sense of "marketplaces of ideas." (100) Grants from the federal government and private enterprise now play an enormous role in the financial structure of universities and other research institutions, which compete for such funding. (101) Accordingly, Washington University, like others, has developed cadres of grant writers, various committees to police possible conflicts of interests and enforce compliance with government procedures, and routine faculty disclosure requirements, (102) not to mention specific arrangements governing the intellectual property that funded research might produce. (103) Whether Masters and Johnson's project would have attracted the external funding that has become so crucial today to conduct research at any university remains an open question.

In addition, faculties have become more fragmented, with the designation of research professorships, clinical professorships, and professors of practice in addition to tenured professors, tenure-track faculty, instructors or lecturers, and adjuncts. (104) This division of labor facilitates specialization and minimizes the distractions that researchers must encounter. These variations in status complicate the tenure system and dilute its protections, which long stood as an important bulwark for the academic freedom necessary to permit research and teaching that challenge prevailing norms and assumptions, as Masters and Johnson's work did. (105)

Further, human studies committees or institutional review boards (IRBs)--required for federally funded research and now used routinely for other investigations as well--have circumscribed the relative freedom that scientists like Masters and Johnson once enjoyed to study whatever they and their subjects deemed worthwhile. (106) The modern-day efforts to protect subjects' sexual privacy and the rigors of the informed consent process no doubt would have inhibited Johnson's ability to reach out to and connect with subjects to convince them through individual conversations of the important contributions that they could make to the sexual lives of others, (107) Although such committees and other safeguards first arose in response to the medical abuses practiced by the Nazis, which prompted the development of a set of principles for ethical research called the "Nuremburg Code," (108) these limits became a systematic part of research practices only after the exposure of scientific scandals in the United States, (109) with reinforcement from a steady string of malpractice cases, which hammered out the contours of legally sufficient informed consent. (110)

Significantly, but not surprisingly, sex exceptionalism infiltrated the regime of human studies committees and IRBs. Authorities regard sex research as a site fraught with extraordinary ethical challenges. (111) For example, confidentiality, which stands out as an essential ingredient of ethical research, could raise special questions in the context of sex research, particularly when spouses and partners are (or are not) involved. Similarly, research benefits must outweigh the risks, which are to be minimized in any event, yet Maier reports that "safe sex" (the use of condoms) became part of Masters and Johnson's protocols only well after the project began. (112) Indeed, some have raised the question whether research like that performed by Masters and Johnson should take place at all. (113) According to one report on the first conference devoted to ethical issues in sex research, convened in St. Louis in 1976, Masters opined that, if the study he began in 1958 "had been subject at that time to the kind of scrutiny now practiced by review committees on human experimentation, the work 'would never have been instituted.'" (114)

It might well be the case that Masters and Johnson's own studies, along with the notoriety of other research focused on sexual matters, helped establish human studies committees and institutional review boards as mainstays of the contemporary scientific and social scientific process. (115) In one illustration of this legacy, IRB officials recently informed the Women, Gender, and Sexuality Studies Program at Washington University that undergraduates (who are legally adults) may not interview or conduct focus groups on any topics that involve sexuality, although this policy was eventually relaxed. (116) Such constraints might well thwart research investigating how androcentric social arrangements curtail the freedoms of women and men alike.

By contrast, contemporary ethics-based hesitations apparently have not stood in the way of the development of Viagra. Psychotherapist and author Leonore Tiefer teases out several aspects of the regulatory context that proved important in what would become Viagra's ultimate triumph over other interventions, including the lack of funding for other sex therapies, "a new academic-industry partnership supporting applied science on university and medical school campuses," and "relaxation of government drug approval policies brought about by industry lobbying and AIDS activism." (117)

Perhaps Viagra simply illustrates a larger "pill for every ill" philosophy. (118) Yet Viagra is not just any pill; as Tiefer notes, sex exceptionalism has cut in favor of Viagra, heightening the urgency and significance of finding and distributing a means to overcome the scourge of male impotence. (119) Moreover, this pill's power extends beyond the medical to the social and the legal, given Viagra's capacity to make sex "all about worshipping the penis" (120) and to inspire new arguments for insurance coverage of contraceptives. (120)

Against this background, legal feminism and the causes that it championed in the Masters and Johnson era appear in a more subdued light today. Although constitutionally protected rights to use contraception and to have an abortion still stand out as pivotal to women's self-determination and full citizenship, that is so primarily because of heterosexist assumptions, including the presumed inevitability of penis-in-vagina intercourse. (122) But even without the gloss suggested by Masters and Johnson's focus on the clitoris as the site of women's orgasmic pleasure, access to birth control and abortion have not fared nearly as well as erection-enhancing drugs like Viagra, which millions of men routinely use today. (123)

First, Viagra's promoters have secured it a visible place in the public consciousness, despite the tradition that treats sex as private. When the subject is Viagra or similar drugs, sex is not too private for public discussion even on television and by public figures (like former Senator and presidential candidate Bob Dole). (124) Although Masters and Johnson might deserve credit for inviting such conversations, couples therapists often say that they find sex too private a topic to broach with troubled clients seeking relationship repair. (125)

In addition, despite recent changes, Medicaid coverage originally included Viagra, on the theory that impotence is a disease and treatment is thus "medically necessary." (126) By contrast, when Medicaid permitted the exclusion of abortion, even for those procedures deemed "medically necessary," the Supreme Court announced that the right to choose to terminate a pregnancy does not include an entitlement to exercise that right, notwithstanding threats to a woman's health. (127) Accordingly, states and the federal government may refuse to provide financial support for indigent women with dangerous pregnancies that they would choose to terminate. Indeed, such tensions between private interests and public funds persist, playing out as contests prompted by contemporary congressional efforts to reform health care. (128)

Early on, Viagra provided a jump start for the movement for contraceptive equity--with some opponents of insurance coverage for birth control appreciating the gendered impact of this approach only after coverage of Viagra became commonplace.(129) Nonetheless, even today, some courts continue to uphold the permissibility of excluding contraceptives from employee health plans, despite federal law's prohibition on sex discrimination (including pregnancy-based discrimination) in employment, the unique disadvantage suffered by women by the exclusion, and the contested plans' coverage of drugs to treat erectile dysfunction for males. (130)

Even beyond such controversies about money, reproductive rights today are not what they once were, with women's access to abortion and contraception showing increased vulnerability to political maneuvers and judicial retrenchment. (131) Moreover, these developments have coincided with the ascendancy of respect for male sexual pleasure--most notably a Supreme Court opinion idealizing gay male anal sex and its role in fostering intimacy. (132) At the same time, the courts have shown considerably less certainty about whether to accord similar constitutional protection for access to sex toys, which facilitate the clitoral stimulation that Masters and Johnson identified as so important for women's sexual pleasure. (133)

Even the feminist law reforms of the Masters and Johnson era have fallen short of the destinations that their original momentum might have suggested they could reach. By and large, formal equality has been won, but little beyond that. Indeed, much of the mainstream talk of sexual equity today has devolved into arguments for a pink pill to match the blue one, even if women would prefer a different type of treatment altogether. (134) In addition, as Katherine Franke has emphasized, legal feminism's preoccupation with workplace equality, work-family balance, rape, reproductive rights, and sexual harassment has produced impoverished or nonexistent theory for a sex-positive regime. (135) Put differently, to the extent that sex exceptionalism has become part of legal feminism, its valence has been almost entirely sex negative, as exemplified by calls for laws singling out sex trafficking (136) and pornography for special punishment. (137) In the meantime, some sex-positive feminists of the earlier era, like Germaine Greer, joined the "backlash," (138) and some queer theorists rose to emphasize their rejection of legal feminism more broadly. (139)

B. The Lens of Fantasy

Although contemporaneous social, legal, and cultural developments go a long way toward contextualizing the contrast between sex therapy then and sex therapy now, an even richer appreciation of opposing understandings emerges through the lens of fantasy. In this section, we explore how different approaches to sex therapy can be seen to embody different fantasies or wishes for different kinds of sexual fulfillment. Examining the fantasies behind different therapies can make visible their contrasting sexual and gender ideals as well as their implicit arguments for particular sexual politics.

Fantasy is defined as a "mental apprehension of an object of perception," "the fact or habit of deluding oneself by imaginary perceptions or reminiscences," or "a day-dream arising from conscious or unconscious wishes or attitudes." (140) Fantasy embodies an idealized or wished-for version of a person, activity, or other aspect of life. (141) These understandings suggest that fantasy represents a bridge between reality and something either desired or feared.

Fantasies may be experienced consciously or unconsciously as images, narratives, verbal concepts, and beliefs that can shape our actions by compelling us to evade understanding, critical thinking, deliberation, and debate. Evidence of fantasy may emerge in dreams, daydreams, parapraxis, jokes, hallucinations, metaphors, symptoms, and behavior in ways often unrecognized. (142) Fantasy's power lies in its ability not only to affect our feelings and judgments, but also to do so endlessly. (143)

Fantasies, as complex webs of tropes, work like the metaphors George Lakoff and Mark Johnson analyze in Metaphors We Live By. (144) While psychoanalysts may focus clinically on a metaphor as "a fragment of an unconscious fantasy," which they view as interfering with reality testing, linguists Lakoff and Johnson argue that the mind engages metaphor in meaning construction in everyday life. (145) To these linguists, metaphor is not evidence of trauma or pathological fixation, as psychoanalysts view it, but a normal, healthy process necessary to all ideation. Their work demonstrates that implicit metaphors shape how we think about everything: "[O]ur normal conceptual system is metaphorically structured." (146) Further, they explain: "Metaphor provides us with a means for comprehending domains of experience that do not have a preconceptual structure of their own. A great many of our domains of experience are like this. Comprehending experience via metaphor is one of the great imaginative triumphs of the human mind." (147)

In illuminating the interpenetration of cognition and affect, Lakoff and Johnson invite us to look more closely for how tropes and fantasies structure every aspect of human life. Earlier, feminist linguists analyzed how gender hierarchy privileged the role of male experience in determining which tropes will be most influential. (148) This gender hierarchy, which is so familiar that we often do not see it, also emerges in our fantasies, including our sexual fantasies. (149)

While fantasy often entails an individual experience or eccentric response to a social script, many fantasies are communal, with shared content borrowed from the surrounding culture. (150) Despite specific historical environmental factors influencing fantasies during particular eras, some fantasies seem more expansive and more enduring, even if they take different forms in different settings. Certain fantasies, like male sexual dominance and female passivity, are part of the longue duree of sexuality, stubbornly resisting change. (151)

Critical discernment can reveal the presence of latent fantasies behind different ways of approaching problems and accomplishing solutions. Such discernment helps us select those practices that are more consistent with our consciously debated and finally chosen ideals, values, and commitments. Danger arises when the promise embedded in a particular fantasy, as played out in our culture, seduces us into buying a product, a project, an answer, a strategy, a politics, or a philosophy that will contradict our more consciously examined values and judgments, even as we understand their social construction.

We identify three types of fantasies active in Masters and Johnson's work and animating the response to that work by their public: We label these categories of fantasy fusional, clitoral, and phallic. All three types of fantasies are enjoyable, and, because people (both women and men in our culture) are generally exposed to all of them, they absorb all to some degree. While it is not, therefore, surprising to find evidence of all three types of fantasies residing in Masters and Johnson's contributions, they did not have equal force either in the cultural imaginary of the 1960s and 1970s, nor do they today. When we connect each type of fantasy to a different sex therapy and thus to a different vision of sexual pleasure, the triumph of Viagra over conjoint and feminist therapies emerges as the triumph of phallic over fusional and clitoral fantasies.

By borrowing child psychoanalyst Melanie Klein's insights into how developmentally primitive fantasies affect adults and cultures as a whole, we can better assess the nature and impact of these different sexual fantasies. (152) In turn, we can see how and why these fantasies play out in our personal and public lives as they do. (153)

According to Klein, immature ideation, along with envy and fear, causes infants to cleave what they experience into ideal and demonized imagery, thereby fueling unrealistic or even destructive interactions. (154) Under Klein' s brand of object-relations theory, infants use all-good or all-bad representations as unconscious defenses against abandonment anxiety that threatens to overwhelm them during periods of stress. (155) To an infant, frustration turns the absent caregiver into a "bad object," while satiation turns her into an ideally "good" one. (156) The infant's use of his or her perceived omnipotence to destroy the bad object seems to save the good one. This process is called "splitting" and entails compartmentalizing the whole person into "part objects," rather than experiencing her as "integrated." (157) Maturation, however, enables the child to blend the good with the bad, shed infantile omnipotence, regret destructive impulses and actions, and take a more humble and less black and white approach to one's relationships. (158) Maturation enables the child to bring the two part objects together into one whole human--an imperfect but loved figure. Adults never entirely outgrow the less mature mode of experiencing the world, however, and splitting returns as the adult regresses, particularly during periods of stress. (159) Thus, Klein argues that inner fantasy radically shapes our outer lives.

As we review sexual fantasies that Masters and Johnson's work indicates were ascendant in mid-twentieth-century culture, as well as those that are discernible today, we might borrow Klein's taxonomy to posit that our culture has not progressed toward maturity as it might have: we have moved from the threshold of living in a more "integrated" stage in which our society (and its members) could absorb ambiguity, imperfection, disappointment, and loss to a psychologically more primitive stage that makes familiar and unremarkable an ethos of disposability, backlash, isolation, and shock-and-awe domination. The stresses intensified by neoliberal elimination of safety nets such as insurance and job security, along with attacks on collective bargaining and deregulation's intensification of competition, not to mention threats to America's long privileged position on the world stage, from the attacks of 9/11 to the economic complexities of globalization, (160) could well push anyone into infantile splitting, fear driven acts of omnipotence, and part-object fantasies. (161)

1. Fusional Fantasy and Conjoint Therapy

We call the first of the three fantasies that we see animating sexual culture "fusional fantasy." Using Klein's approach, we regard this fantasy as immature, because of both its roots in the mother-infant relationship and its idealization or "all-good" depictions of certain adult sexual interactions.

What immediately struck us in Thomas Maier's story of Masters and Johnson's founding of contemporary sex therapy in the 1950s and 1960s were the images of mutuality embedded in the techniques they used to treat sexual dysfunction--from conjoint treatment and dual-sex therapists to exercises that made touch itself an important therapeutic tool. (162) Masters and Johnson emphasized that the quality of the couple's relationship played out in their sexual interactions, and they coached their patients to empathize with each other and to strive for emotional intimacy to lay the groundwork for what the therapists considered the apogee of sexual experience--simultaneous orgasms during intercourse. (163)

The therapists' approach expresses the fusional fantasy of romance, love, devotion, nurturance, and commitment; the joys of mutual pleasure; and the dissolving of personal boundaries and individual loneliness in an achieved oneness. This is the dynamic found in romance novels, in which couples come together wordlessly, so perfectly are they attuned to each other. (164) Speaking is unnecessary; a special chemistry does all the work.

This is a sexual fantasy of hyper-secure attachment, which derives from idealizing mother-child intimacy. (165) Audre Lorde's words might apply to this fantasy: "The erotic is a resource within each of us that lies in a deeply female and spiritual plane, firmly rooted in the power of our unexpressed or unrecognized feeling." (166) The "deeply female and spiritual plane" is the caregiver's holding of the infant and reflecting back to the infant unreserved love and affirmation. While masculinity prematurely splits off or limits access to this realm, femininity makes it the source and measure of all relational orientation and practices, in turn giving rise to the all-good fantasy of eternally egalitarian love and partnership. (167) Connection and power-with characterize the fusional fantasy of mutuality, which often motivates men's as well as women's sexual conduct with its idealized images of human bonding and connecting over those of separating and differentiating. (168)

Arising in the era of marital/couples therapy and second-wave feminism, Masters and Johnson's approach inherited and passed on the fantasy of heterosexual complementarity and mutuality, conceptualized by one school of feminism and adopted by couples therapy, yet never publically regarded as a specifically feminist contribution to therapeutic thought. Although neither Masters nor Johnson consciously affiliated with either movement, (169) they employed the conjoint perspectives and methods of couples therapy, and they recognized feminists' call for mutuality and respect as the very ingredients they were discovering were required for "successful" sexual interactions. (170) Their nurturing approach took a couple's sexual capabilities and sought gently to help them learn how to experience frequent, successful performances of heterosexual intercourse.

While Virginia Johnson never identified herself with feminism, she did see herself as a therapist, and it is hard to know how much the rise of couples therapy influenced Masters and Johnson's work. Recall that Masters and Johnson's work was legitimated by its promise to stabilize marriage and curtail divorce. (171) The therapy project, situated in its own cultural context, was consciously heterosexual and marital.

Whether Virginia Johnson or Virginia Satir invented conjoint therapy, in which the couple's relationship rather than the individual self constitutes the unit of treatment, remains unclear. Both women's practices emerged during a time of concern for civil rights and equality. In teaching "peoplemaking" in the 1950s and 1960s, Satir emphasized the need for mutual respect: "Intimacy," she would say, "is simply the freedom to respect the spaces between people--to go in when there is an invitation, and not to invade when there isn't one." (172) Similarly, Masters and Johnson taught their clients that without power sharing, the relaxation they prescribed as essential to sexual success proved difficult to attain. (173) Masters and Johnson recognized that domination or even slight bossiness squelched the rapport heterosexual couples needed in order to give and get sexual pleasure. For that reason, they taught non-demanding touching and communication skills to sexually inept couples. (174) These equality-producing techniques were like some of the very lessons couples therapists were coming to recognize as those most likely to help troubled couples improve unsatisfactory relationships.

Couples therapy, which today proclaims equality in power relations the sine qua non of couples' satisfaction, has arrived at a surprisingly feminist destination, given its patriarchal start in the Nazi hygienic movement. (175) Perhaps its story can help us understand the prominence of fusional fantasy in Masters and Johnson's work. In Germany in the 1920s and 1930s, hygienists sought to improve "the race" by creating better mothers and wives. They worked to instill patriarchal values, like deference and love of self-sacrifice, in the hearts and minds of women, and they shaped messages to counter feminist ideas of the times. We can see these goals also influenced contemporaneous handbooks advising married couples in sexual technique. The most popular of these manuals, Henrik Van de Velde's Ideal Marriage, which produced seven English editions in the United States, defines normal intercourse ("communion") as heterosexual and "having consummation as its goal--the ejaculation of semen into the vagina as both man and woman reach climax simultaneously." (176) The role of sex to reproduce proper gender hierarchy is evident in his following advice: The "Attitude of Equitation" (woman astride the man) may bring about passivity in the male if used too often," and that is "directly contrary to the natural relationship of the sexes." (177)

This view of the naturalness of gender hierarchy diverges 180 degrees from the one embraced by leading couples therapists today. Current icons in the field, such as John and Julie Gottman, Susan Johnson, Alan Gurman, Robert Taibbi, and Daniel Wile, use evidence-based practices that aim at helping couples achieve equality in their interactions and at dissolving hierarchy and domination in their relationships. (178) The Gottmans define "the four horsemen of marriage destruction" as "criticism, defensiveness, contempt and stonewalling." (179) These stratagems of power and domination express lack of respect, and they impose what domestic violence theorist Evan Stark describes as "coercive control." (180) Stark views men's conventional subjugation of women as robbing them of the freedom to pursue their own projects and interests and so depriving them of the liberty our society grants citizens. (181) When exercised in the bedroom, coercive control occludes the spontaneity and mutual playfulness and respect Masters and Johnson thought necessary for sexual arousal and pleasure.

Because it is doubtful if these mainline couples therapists identify as feminists, we must recognize the origin of their discipline's commitment to partners' mutuality in mid-twentieth-century feminist discourses of gender equity. Egalitarian marriage and female sexual autonomy are two such ideas the wider culture has appropriated from feminist platforms without crediting feminism for their conceptualization or promotion. Jennifer Baumgardner and Amy Richards describe a dominant pattern in which the role feminism plays in intellectual history is routinely erased. (182) When wider society co-opts and appropriates successful projects, findings, and results from feminism, it disconnects the successful innovation from its feminist roots. Baumgardner and Richards cite the antebellum abolition movement, the 1972 movement to stop violence against

women, the women's health movement that began in the 1970s, recent microlending programs for individual development accounts, and the twentieth- and twenty-first century protest against female genital mutilation as examples of feminist programs adopted by the nation at large but later severed from their feminist origins. (183) Few people realize that feminists pursued suffrage not primarily as a political movement. (184) Rather, nineteenth-century feminists slowly came to embrace the vote as the only way women could exert the power needed to reclaim their bodies and their lives from a society organized around coverture, which rendered women the property of their husbands in the eyes of the law. (185) Couples therapy and sex therapy are thus heir to both feminism's insights and anti-feminism's amnesia.

While those currently in power may regard feminism as an attack on their privilege, a perception reminiscent of the infantile or immature mode of interaction, equality for all is one primary tenet of several stripes of feminism. True, fusional fantasy does not include power over the other, but, rather, mutuality with the other. Yet, it contains a dream of perfect mutuality uninterrupted by conflict or the need to hammer out differences. Its idealization of harmony and togetherness would place it closer to Kleinian primitiveness than to integration. In other words, its inability to let go of the all-good ideal marks this fantasy as immature.

2. Clitoral Fantasy and Vibrators

We name the second of the fantasies that we find "clitoral fantasy." Clitoral fantasy, although almost universally marginalized, often generates images of female sexual fulfillment beyond conventional intercourse and gives rise to aspirations for personal power. (186) Clitoral fantasy has nothing to do with reproduction and, as such, does not conflict with women's autonomy. Separated from procreation, clitoral fantasy does not fit with traditional understandings of sex. (187) By contrast, in clitoral fantasy, women's sexuality is not depicted as secondary, self-sacrificing, or as a gift to men. (188) Nor is it even necessarily depicted as partnered sex or heterosex. Clitoral fantasy accords greater recognition to women's special pleasures as differentiated from, and not necessarily parallel to, men's. In partnered sex, clitoral fantasy embraces taking turns, reciprocity, and even selfishness.

More than the other fantasies, clitoral fantasy entails communication. Creating new scripts for how to come together requires collaboration. Clitoral fantasy eschews the idealization of wordless fusion in favor of a more realistic understanding that, when two (or more) individuals engage in a sexual interaction, they must negotiate to maximize their pleasure, and they must also accept imperfection. Irving Kenneth Zola's moving description of a sexual encounter between two individuals with physical disabilities exemplifies these features of clitoral fantasy, (189) which we classify as mature under Klein's approach and hence superior to fusional fantasy.

Clitoral fantasy combines desire and orgasmic experience, both of which suffuse the whole body with pleasure. (190) Psychoanalyst Heinz Lichtenstein calls orgasm the most intense moment in which one experiences "the I am," and he asserts that enacting this experience repeatedly builds up a person's ego, contributing to his or her agency and efficacy. (191) Others celebrate orgasmic experience for the quite different reason that it uniquely dissolves and erases personal limits, disrupting "the organization of the self." (192) In clitoral fantasy, sex combines contrary experiences, opening up a space for enjoying ambiguity.

When Masters and Johnson revealed that women's orgasms were always triggered by the clitoris rather than by a responsive vagina, they might have inaugurated a radically new age in which women would be permitted to enjoy sex for themselves and on their own terms, giving them greater access to autonomy. So entwined is sexual pleasure with power in other realms, one report suggests that women who do not feel entitled to demand equal sexual pleasure from their male partners also do not feel entitled to ask for raises at work, while sexually self-confident women are much more likely to pursue entitlement on the job, as well as in the bedroom. (193)

Clitoral fantasy, however, has never enjoyed the prominence of fusional fantasy. Indeed, what is impressive is its survival despite enduring marginalization and invisibility. As Rachel Maines's historical research documents, deeply and fiercely held androcentric understandings of sex--long before Freud as well as after--entrenched and perpetuated misconceptions about women's bodies, desires, and sexual experiences, with the clitoris as one notable victim. (194)

Although references to clitoral massage to orgasm for therapeutic purposes appear as far back as the time of Hippocrates, (195) as Maines explains, such practices and sensations were not generally regarded as sexual, given prevailing assumptions that penis-in-vagina penetration alone constituted sex and that proper women lacked sexual desire. (196) Rather, thanks to "social camouflage,'' (197) clitoral stimulation emerged as a medical treatment for "hysterical" women--a category so broad prior to Freud's reformulation of the concept (198) that almost all women fit the bill. Symptoms of the would-be disease included nervousness, loss of appetite for food and marital intercourse, and insomnia. (199) Causes were thought to include insufficient sexual intercourse, insufficient gratification, and a propensity to masturbate. (200) Medical intervention was designed to induce the "hysterical paroxysm." As Maines points out, perceiving the majority of women as sufferers of sexual pathologies proved far more obvious and certainly less threatening than revising the androcentric understanding of orgasmic pleasure and redefining sex itself. (201)

Well-known members of the medical establishment across the years who saw clitoral massage and paroxysms as an effective treatment include Galen of the second century, (202) Forestus and Highmore of the seventeenth century, (203) and Briquet of the nineteenth century. (204) Although early practices entailed manual treatment and sometimes "hydrotherapy," a significant turning point in treatment methodology occurred at the beginning of the twentieth century with the advent of electricity and the subsequent development of the electromechanical vibrator, often associated with Joseph Mortimer Granville. (205) Such technology and its efficiency in producing the desired results allowed physicians to increase the number of patients served, and these patients almost always returned for more treatment, making the practice ever more lucrative. (206) Still, because "sex" was reserved for penis-in-vagina penetration, these physicians' interventions were understood as therapy but not as sex therapy.

We have little direct evidence of the thoughts and emotions of the "hysterical women" receiving this treatment. Presumably, some of them embraced the dominant myth that women should not have sexual feelings. (207) We do not know whether the "social camouflage" that Maines analyzes (condemned by others as the active production of ignorance (208) snuffed out clitoral fantasy for these women or permitted them to enjoy their fantasy so long as it remained their own secret.

Although we may not have any actual patients' accounts of the clitoral cure and associated fantasies that may have ensued, we do find clitoral fantasy expressed in women's clinical data, literature, and art. In her imaginative effort to fill the gaps in our understanding of how patients experienced such medical intervention, contemporary playwright Sarah Ruhl juxtaposes a physician who does not grasp the sexual nature of the treatment he administers with several female characters who--even if they never abandon fusional fantasy--gradually display varying degrees of appreciation for what happens in the doctor's "operating theater." (209) Without comprehending the full meaning of his words, this physician delivers the line used above as our second epigraph (about all that the intellect prevents men from seeing), which emphasizes not only the limits of knowledge but also the difference that gender makes in constructing and legitimating knowledge. (210)

Many other examples complement Ruhl's dramatic approach. Nancy Kulish reviews the psychoanalytic literature studying analysands' representations of the clitoris and supports her interpretations with images from fairy tales, myth, and children's games. (211) While she concludes these images evidence women's fear of the clitoris, other interpretations might be more compelling. (212) Nineteenth-century women writers often alluded to "family jewels" inherited from mothers, precious "pebbles," and twirling experiences that delighted as well as disturbed. Paula Bennett enumerates over 287 imagistic references to the clitoris in the poetry of Emily Dickinson alone. (213) Bennett points out Dickinson accorded "inestimable value" to what images of "peas, pebbles, beads, berries, nuts, buds, crumbs, pearls, pellets, dews, gems, jewels, drops, and ... bees" represented and accorded these images primacy in her writing. (214) Women may often see the clitoris as Dickinson and countless other female writers and artists have, as providing the pleasure and relaxation that could fuel their sense of self and agency. (215) In the twentieth century, the work of Virginia Woolf has evoked analyses examining her references to the clitoris, to orgasm, and to "the importance of autoeroticism to female identity, creativity, and fulfillment." (216) Closer to our own century, the self-portraiture of Carolee Schneeman includes explicit images of her clitoris:
   One of the startling aspects of this image of my naked body is
   that it includes a visible clitoris. Western, masculinist art
   history has been obsessed with the female nude, but the image
   of a contemporary artist as a genitally sexed nude sets off a
   tireless round of inquisition: what is the meaning of this
   "obscene" image? (217)


The outrage Schneeman's work provokes highlights why these fantasies and the images they inspire seem so ephemeral. The clitoris and clitoral fantasy rub up against an uncongenial patriarchal culture, which elsewhere expresses itself even more forcefully, with the violence of female genital mutilation. (218)

Masters and Johnson's validation of clitoral orgasms' inaugurated a resurgence of research and writing about clitoral pleasure. Shere Hite's subsequent work, for instance, paved the way for Maines to uncover and interpret historical medical practices and for Ruhl to bring them to life. (219) In addition, Masters and Johnson's findings invigorated clitoral fantasy, from which emerged such modern sex-positive feminist interventions as vibrators and other sex toys designed by women for women, Tupperware-style house parties organized to sell these products, (220) and Betty Dodson's famous lessons (in person and on videotape) on "solo sex." (221) While Masters and Johnson never shed their heterosexist assumptions, continuing to see penis-in-vagina intercourse as the holy grail of sexual activity, (222) the rise of sex toys intended for clitoral stimulation and the celebration of women's masturbation have not been similarly confined. Often these orgasm-promoting techniques serve as an aid in heterosexual relationships, (223) but these techniques also facilitate same-sex and solitary pleasures. (224) Moreover, although inspired by Masters and Johnson's work, these interventions are not necessarily understood as "therapeutic" because their consumers and advocates do not regard heterosexual intercourse's persistent gendered orgasm gap as evidence of sexual dysfunction. (225) Put differently, while vibrator use was once seen as therapy but not sex, today it is more likely to be seen as sex but not therapy. And precisely because such sex marginalizes the penis and is nonprocreative, access to such devices continues to be restricted by law in some states. (226)

In any event, although Masters and Johnson documented the importance of the clitoris and emphasized egalitarianism as important to attaining pleasure in heterosexual experiences, the researchers nevertheless assumed an essentialist framework that idealized the coital imperative. That all women could and should orgasm during sexual intercourse is a fact upon which Virginia Johnson still insists. (227) Accordingly, Masters and Johnson taught ways to stimulate the clitoris during intercourse and techniques to extend the erection's longevity, not "outercourse" methods of attaining orgasm through non-penetrative sex acts or use of sex toys. (228) Their work fueled clitoral fantasy, but never sought to make it preeminent. What Masters and Johnson found about women's greater sexual capacity meant that their emphasis upon the coital imperative would ironically produce expectations for even more heroic performances from both men and women. It would not be enough to attain orgasm during intercourse, after women's multiple orgasms became a norm. Men, already besieged by performance anxiety fueled by dominant gender scripts, would now have to fulfill women's expanded sexual capacity. (229) Not surprisingly, Masters and Johnson's work led to a search for something to prop up male sexuality by improving the penis's performance.

While clitoral fantasy could fuel a manic female sexuality, this fantasy arguably lets go of the grandiose sexual ideal of simultaneous orgasm during heterosexual penetration. While calling it "clitoral fantasy" seems to identify it as a primitive, part-object fantasy focused on one anatomical bit, studies show female orgasm is more often experienced as a full-bodied response. (230) Thus, clitoral fantasy seems a reflection of the more mature, integrated Kleinian subjectivity than of the less mature, split subjectivity. Although clitoral fantasy does not embrace concern for the other so much as delight in the self, it is not a fantasy of coercive domination. Clitoral fantasy is all about self, empowerment, acceptance of limitations, and perhaps the joy of being recognized by another and having one's sexual desires validated as legitimate. (231) This is a feminist fantasy in that it embodies power-with rather than power-over, as suggested by the popular song "I Am Woman," which became an anthem for the women's movement in 1972. (232) If fusional fantasy captures important elements of second-wave feminism, then perhaps clitoral fantasy might be aligned with what is now called the third wave. (233)

3. Phallic Fantasy and Viagra

The third of the fantasies we found in studying Masters and Johnson's work, and the one that has maintained cultural hegemony, is what we call "phallic fantasy." Phallic fantasy also embodies the thrill of power, but here it is power either masochistically or sadistically experienced. This is a sexual fantasy found in hierarchically arranged relationships. Dominance, privilege, and power-over constitute the appeal of this fantasy. Phallic fantasy idealizes success resulting from quest, dominance, and exploitation. This fantasy drives the plot in Western history: the world is recalcitrant, and man must transcend its exigencies. When William Masters set out to explore new scientific territory and to conquer ignorance about sex, in defiance of prevailing social and academic norms, he acted out this fantasy.

Phallic fantasy, like the "all-good" fusional fantasy, reflects immaturity under Klein's approach. Masculinity theorists describe phallic fantasy as "hegemonic masculinity," (234) which drives men to flee from women and repudiate femininity. (235) Michael Kimmel sees the boy "renouncing his identification with and deep emotional attachment to his mother and then replacing her with the father as the object of identification." (236) But the boy never reattaches. Kimmel describes oedipal neurosis: "The flight from femininity is angry and frightened, because mother can so easily emasculate the young boy by her power to render him dependent, or at least to remind him of dependency." (237) The rest of his life he seeks to attain unattainable ideals of masculine self-sufficiency, all the while straggling to "be a man" in the eyes of other men. His struggle leads him to sexual conquest and other "markers of manhood--wealth, power, status, sexy women--in front of other men, desperate for their approval." (238) Kimmel claims that the need for men to "prove their manhood in the eyes of other men is both a consequence of sexism and one of its chief props.... Masculinity is a homosocial enactment. We test ourselves, perform heroic feats, take enormous risks, all because we want other men to grant us our manhood." (239) Homophobia then, is not irrational fear of gay men, but rather, the fear of all men. It is driven by the "fear that other men will unmask us, emasculate us, reveal to us and the world that we do not measure up, that we are not real men." (240) Phallic fantasy is homophobia, and it drives men endlessly to prove they can measure up--"up" being the operative word.

While many feminists hailed the revolution-making results of Masters and Johnson's research into female sexuality, (241) the sex researchers' work also led to a resurgence of phallic fantasizing and renewed insistence upon and reinstitution of sexual phallocracy over the feminist "dream of [finding] a common language," (242) and sexual interactions involving more mutual pleasure than received under patriarchal arrangements. We should note that surveys conducted at the end of the twentieth and beginning of the twenty-first centuries called for improving heterosexual sexual relationships. (243) One of these, an international survey of 27,500 people between the ages of forty and eighty, conducted by University of Chicago sociologist Edward Laumann, found that gender equality leads to better sex lives. (244) He also found that, among Western nations, one half of the men and one third of the women surveyed said that sex was extremely important to them. (245) Laumann reported a strong correlation between satisfaction with one's sex life and with one's life in general. Given the results of sociological research, one would have thought that the sexual improvement that transpired would have been in the direction of recognizing what women's preferences and skills could add to the sexual repertoire (which, after all, is learned (246)), enhancing either mutuality or "cultural cliteracy." (247) But a fundamentally different shift occurred.

Masters and Johnson's "discovery" of the human sexual response cycle reinvigorated the appeal of the coital imperative: the idea that heterosexual intercourse, which some feminists have called the bedrock of male domination, is the only "natural" sexuality. Masters and Johnson's human sexual response cycle incorporates the imagining of a sexologist looking for universal scientific law rather than the work of a therapist looking for pragmatic ways to help people become more sexually and relationally self-efficacious. Masters modeled himself on Alfred Kinsey, perhaps the best-known American sexologist, who had died in 1956, only months before Masters started his own sex research. (248) Sexology's canon includes nineteenth- and twentieth-century works by sex researchers Richard von Krafft-Ebing, Iwan Bloch, Clelia Duel Mosher, and Kinsey, among others. (249) Because the basis of this kind of research is the scientist's wish to name and so dominate nature, the positivist framework makes it hard to see things from "the other's" point of view.

Postmodern critics of Masters and Johnson's methodology claim that the St. Louis researchers constructed the universal law they purported to have discovered. These critics show that the human sexual response cycle, which Masters and Johnson described as proceeding through excitation, plateau, orgasm, and resolution, (250) was actually a template that the researchers imposed on their observations, rather than a pattern found within them. (251) Their methodological aporia resulted from their conviction that the coital imperative represented a universal and hardwired human reality. For them, "sex" was defined as penis-in-vagina penetration, thrusting, and ejaculation. (252) Although their findings debunked Freud's notion that female clitoral sexuality manifested female immaturity (253) and they claimed to embrace an expansive understanding of sexuality, (254) they never gave up Freud's belief in the normality of penis-in-vagina sex as the true money shot. (255) Critics point out that they skewed their research sample by including only participants who reliably achieved orgasm during heterosexual intercourse, a capability estimated to be present in only one-fifth of all women. (256) When research subjects had difficulty performing as expected, Masters and Johnson coached them how to attain better results, so that their performances were shaped, not simply observed, by the researchers. (257) Ironically, as Masters and Johnson aimed to work therapeutically to disarm clients' performance anxieties, their theories and findings imposed standards that made other possible models of sexual response "inadequate."

If the human sexual response cycle represented a universal biological fact, divergences from its stages would constitute not diversity but pathology. Recent studies find most men agreeing that penetration forms the center of their sexuality, (258) while giving voice to women's different preferences. (259) According to such studies, women report that sensuality, intimacy, closeness, and, of course, orgasm are not achieved by penis-in-vagina sex as well as they are by other forms of sexual expression. (260) Alan Riley found that virtually all men in his study preferred penetrative sex, (261) while over 50 percent of women preferred other sexual activities, and many surveys confirm the gendered orgasm gap experienced in traditional heterosexual intercourse. (261) Such results validate non-coital representations of female sexuality that women literary artists have created in their works for centuries. (263) Although gender scripts undoubtedly play a role in shaping these expressed preferences, Masters and Johnson's model nonetheless disciplined couples to follow the researchers' own strict script. (264) This script infallibly arrived at penis-in-vagina intercourse, in turn placing performance expectations on men, often leaving women sexually frustrated (or "hysterical," to use the old term (265)), and taking an emotional toll on both. Couples who fail to practice sex according to this pattern are considered abnormal. The nosology of "sexual dysfunction" entered the DSM III in 1980, and penises rather than clitorises, whose newly discovered rapid-fire capabilities could have suggested all kinds of new sexual practices, remained at the center of approved sexual scripts. (266) Penises, with all their frailties, were thus well positioned to become the focus of plans to enhance their reliability.

What props up male sexual dominance is phallic fantasy--belief in male power and a form of grandiosity emblematic of Klein's notion of developmental immaturity. (267) Women as well as men entertain phallic fantasy. The idea that there is power, significance, and protection, or that someone can produce those things, is seductive. Women are typically socialized to prefer masculine men, those who are strong, with powerful sex drives. (268) While women are complicit in phallic fantasy, men are socialized to desire to incarnate these ideals. (269) Although current estimates say that one in ten men struggles with erectile dysfunction, conventional wisdom has it that men are naturally driven to frenzy by sex and are always ready and willing to perform it. (270) When these ideals become reality, phallic fantasy consolidates, justifying the conventional gender hierarchy it reproduces. Yearning for the gratification that phallic fantasy offers makes us fall for products that promise we can attain it and perpetuates harmful myths and practices.

Masters and Johnson's discoveries of men's sexual "inferiority" were not to proceed unchallenged. Within twenty years after the publication of their first book, Human Sexual Response, technological invention promised to re-establish the penis as the reliably powerful hegemonic sexual organ it had previously been. (271) The 1998 introduction of Viagra has led to over thirty-five million men taking some form of an erection-enhancing drug today, most without benefit of counseling about other aspects of sexual interactions, including pleasurable alternatives to penis-in-vagina intercourse. (272) (Recall Masters and Johnson's sensate-focus exercises or even their controversial work with single men and surrogates. (273)) While sex therapists who use evidence-based practices integrate sex therapy (often for couples) with the use of Viagra, when indicated, to treat interpersonal and sexual difficulties holistically, general practitioners, who are a much larger group and who treat many more patients, usually dispense Viagra to treat the penis alone. (274) Fortifying phallic power rather than creating equality-producing interpersonal mutuality or celebrating clitoral pleasure seems to be the sex therapy of preference in America today. Selling a profitable commodity trumps less lucrative ways of fostering capability. (275) By contrast, had contemporary conjoint therapy caught on as the primary remedy for sexual problems, it could have provided a useful forum, valuable practices, and new scripts for men and women struggling to renegotiate the personal power struggles patriarchy had bequeathed to them. (276) This model might well sometimes entail dispensing Viagra, while at other times validating the clitoral source of women's pleasure or including sex toys as possible strategies. It might involve couples, or it might focus on an individual's sexual interactions. In other words, it would have built on the ideas that any sexual encounter is relational and that communication is valuable. (277) But this model would eschew treating a body part in isolation and excluding consideration of partners' experiences and wishes, as most Viagra prescribing physicians do today. (278)

When approving Viagra to market in 1998, the FDA did not formally take into account the impact on women of men's use of the drug. (279) Several later studies cite the dissatisfaction of female partners of Viagra users. (280) Some say it makes erection and penetration too important. A fifty-one year old woman's complaint is representative:
   So here we are at that stage of our life and ... as things are
   quieting down in your life and you're ... becoming friends
   and yes, there's a closeness and a friendship and yes sex did
   happen occasionally but quite rarely as you're getting older,
   and to me that wasn't a major problem ... and all of a sudden
   Viagra ... became a main focus in the house.... (281)


Another protests that it takes the negotiation out of the couple's relationship. (282)

While urologists were advising that erectile dysfunction was "all hydraulics," conjoint sex therapists were pointing out not only that you cannot treat the penis separate from the man, but also that you cannot treat it separate from the relationship. (283) According to a firm principle of Masters and Johnson's original method of sex therapy, the relationship is the context for negotiating pleasurable interaction, (284) including (when pertinent) attention to the clitoris, and this principle holds whether the relationship is long-term or fleeting, (285) same-sex or different-sex, dyadic or larger. (286) True, Masters and Johnson principally focused on married couples, but their insights have more expansive applications.

The relationship challenges precipitated by Viagra's triumph could have inspired a return to the learning of Masters and Johnson, one perhaps supplemented by more recent acceptability of vibrators. What has happened instead, however, is a shift in attention to a new drug thought to make women more receptive to men's Viagra-enhanced eagerness for penetration. (287)

A new drug, like Viagra itself, holds far greater economic promise than counseling alternatives. The dual-sex sessions proposed by Masters and Johnson might have provided a nice income for individual therapists or teams--assuming that patients whose insurance typically does not cover such care could pay themselves--but the course of treatment was meant to be short. (288) Moreover, the model is a decentralized one in which decisionmaking, control, and any profits belong to the individual practitioners or clinics, rather than to a large corporation with an enormous advertising budget and an international reach. (289) When first introduced, Viagra was covered by social insurance programs, namely Medicare and Medicaid; many insurance programs still cover such prescriptions, but limit conjoint sex therapy. (290) Further, the sex therapy that Masters and Johnson developed, once completed, does not entail repeated return visits--unlike the bygone treatment for "hysteria" through physician-administered paroxysms, for which patients could be expected to "need" such interventions on a regular basis. (291) Indeed, once vibrators and sex toys became available for individual purchase, doctors lost this "lucrative market." (292) Although manufacturers and sellers of products designed for women's pleasure have enjoyed some recent economic success, even in states where these devices may be legally sold, such products cannot compete with Viagra's immense economic rewards. (293) Only a pill to be taken regularly for the rest of one's life can scale such financial heights. Indeed, given the stake of the pharmaceutical companies and their advertisements pitched directly to consumers, Viagra and similar drugs undermine medical authority. (294) That attention has now turned to a drug for women--and one that is compatible with men's use of Viagra and not directly clitoris focused--should come as no surprise. (295)

III. CONCLUSION: WHY IS THE SEX THAT SELLS BEST VIAGRA SEX?

Modern sex therapy's journey reveals that Viagra, which embodies phallic fantasy, has repackaged male dominance and successfully remarketed male supremacy with the little blue pill. When Foucault explains his concept of bio-power as a mode of domination that has evolved in late consumer capitalism, one that coerces through pleasure rather than through fear of sovereign force, he helps us recognize the insidious power of Viagra. (296) Bio-power uses the carrot rather than the stick approach. Foucault claims that in order for domination and oppression to be efficacious under late capitalism, it must seduce people into complicity. (297) Contemporary hegemony thus develops and uses power that works from within the psyche by creating desire for particular experiences and products, rather than from without by creating fear and dread of physical violence. When bio-power works through consumer products, it often markets its wares by connecting them to sex and sexual fantasies.

But, given the allure of alternative therapies, why is the sex that sells best Viagra sex? As we have shown, each sex therapy--in attempting to address a sexual problem--necessarily reflects a normative vision of sex. Yet, once contextualized in a wider frame that includes social scripts, law, politics, and fantasy, (298) such visions help foreground familiar assumptions and values that ordinarily remain both taken for granted and invisible in the background, (299) exerting their power imperceptibly. (300) Viagra triumphs because it fits so seamlessly into our neoliberal times; indeed, it helps construct this masculinist ideology. Just as other observers highlight evidence of neoliberalism in sexual practices such as barebacking (301) and some forms of "hooking up," (302) so too may we cite Viagra--with its economic rewards, individual focus, prioritization of the physical over the emotional, enactment of dominance, and celebration of phallic fantasy.

The sexual problem that Viagra seeks to cure is the threat to gender hierarchy posed by the other therapies and fantasies. Masters

and Johnson's discoveries of the clitoral site of orgasms and women's impressive sexual capacities, as well as their "feminist" approach to therapy, all invited questions about the preeminence of penis-in-vagina sex, alternative paths to pleasure, and women's sexual interests. (303) But Viagra crowded out the new learning and the additional innovative scripts it promised.

Viagra re-establishes the more familiar and enduring order, in turn, evoking collective celebration and relief--as perhaps most vividly depicted in a television commercial for Viagra in which diverse males all come together to rejoice that they can proclaim, once again, "We are the champions!" (304) Viagra treatment shapes the sex that naturalizes the hierarchy embodied in phallic fantasy, (305) without anyone's seeming to question the need for this bionic, pharmacological, and thus "unnatural" prop. In constructing our sexuality to accord with patriarchal assumptions, we then reproduce male dominance in nonsexual as well as sexual realms. Flibanserin provides only more of the same, and we suspect that the discontinuation of its development does not mark the end of efforts to invent a pink pill, but rather an impetus to cultivate alternative formulations. (306)

Our account has traced how Viagra has trumped a feminist program that could have expanded gender equality by inviting people to engage in mutual, communicative, and reciprocal interactions or to accord more attention and legitimacy to the clitoris. This story of sex therapy has two discernible lessons: First, in these neoliberal times, money--a materialization of phallic fantasy--overcomes love, often even in the name of love. Second, interventions that ask us to be present and do what we fumblingly and imperfectly can do will lose out to a quick fix promising to give us the idealized kind of sex the dominant fantasy teaches us is sexy. (307)

([dagger]) THE BEATLES, Can't Buy Me Love, on A HARD DAY'S NIGHT (United Artists Records 1964).

(1.) JEFFREY WEEKS, SEXUALITY 99 (3d ed. 2010).

(2.) SARAH RUHL, IN THE NEXT ROOM OR THE VIBRATOR PLAY 44 (2010) (line delivered by Dr. Givings).

(3.) Duff Wilson, Drug for Sexual Desire Disorder Opposed by Panel, N.Y. TIMES, June 18, 2010, at B3, available at http://www.nytimes.com/2010/06/19/business/19sexpill.html; see Press Release, Boehringer Ingelheim, Following Regulatory Feedback Boehringer Ingelheim Decides to Discontinue Flibanserin Development (Oct. 8, 2010), available at http://www.boehringer-ingelheim.com/news/news_releases/press releases/2010/08 october 2010 fliba. html.

(4.) See, e.g., Katrina vanden Heuvel, Editorial, For Pink Viagra. a Double Standard, WASH. POST, June 9, 2010, http://www.washingtonpost.com/wp-dyn/content/article/2010/06/ 08/AR2010060802274.html. Hugh Hefner calls Viagra "God's little helper." Deborah Solomon, Questions for Hugh Hefner: Sex and the Single Man, N.Y. TIMES, July I 1, 2010, [section] 6 (Magazine), at 13.

(5.) See Rob Stein, FDA Considers Endorsement of Drug That 5'()me Call a Viagra for Women, WASH. POSY, May 24, 2010, http://www.washingtonpost.com/wp-dyn/content/article/ 2010/05/23/AR2010052304206.html.

(6.) Sildenafil citrate, the key ingredient in Viagra, increases blood flow and thus corrects for hydraulic problems that hinder male erections. Flibanserin, by contrast, works on women's neurochemicals to fix "hypoactive sexual desire disorder" or absence of desire. Catherine Elton, Female Sexual Dysfunction: Myth or Malady?, TIME, Nov. 18. 2009, http://www.time.com/time/health/article/0,8599,1939884,00.html.

(7.) See, e.g., Daniel Bergner, What Do Women Want?, N.Y. TIMES, Jan. 25, 2009, [section] 6 (Magazine), at 26 (explaining how Viagra not only inspired a search "to find drugs that can foster female desire as reliably as Viagra and its chemical relatives have facilitated erections, but also help[ed], indirectly, to inspire the search for a full understanding of women's lust").

(8.) Our reference to "money" encompasses corporate profits and global marketing.

(9.) According to one definition:
   "Neoliberalism proper" is the set of principles about the economy's
   workings, and the economy's relations to society, politics and
   government, that emerged originally in economic thought but, under
   particular circumstances, in the 1980s-2000s, developed into a
   dominant "doctrine" for political and social organization ....

   ... At its simplest, it is the principle that market functioning is
   the privileged reference-point for organizing how
   governments--indeed, all modes of social organization--must
   operate. This overrides other political principles, whether of
   social welfare, non-market ("public") provision of goods, services
   or resources, or nonmarket modes of bureaucratic organization.


NICK COULDRY, WHY VOICE MATTERS: CULTURE AND POLITICS AFTER NEOLIBERALISM 23 (2010); see also DAVID HARVEY, A BRIEF HISTORY OF NEOLIBERALISM 2 (2005) (defining neoliberalism as "a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property fights, free markets, and free trade," with "+the role of the state . . . to create and preserve an institutional framework appropriate to such practices").

(10.) See WEEKS, supra note 1, at 99. The Sexuality Information and Education Council of the United States (S1ECUS) offers the following definition:
   Human sexuality encompasses the sexual knowledge, beliefs,
   attitudes, values, and behaviors of individuals. Its various
   dimensions involve the anatomy, physiology, and biochemistry of the
   sexual response system; identity, orientation, roles, and
   personality; and thoughts, feelings, and relationships. Sexuality
   is influenced by ethical, spiritual+ cultural, and moral concerns.
   All persons are sexual, in the broadest sense of the word.


Position Statements, SIECUS, http://www.siecus.org/index.cfm?fuseaction=Page.viewPage& pageId=494&parentID=472 (last visited Apr. 29,2011).

(11.) THOMAS MAIER, MASTERS OF SEX: THE LIFE AND TIMES OF WILLIAM MASTERS AND VIRGINIA JOHNSON, THE COUPLE WHO TAUGHT AMERICA HOW TO LOVE 179 (2009).

(12.) See id.

(13.) See supra note 9 and accompanying text.

(14.) MATER, supra note 11, passim.

(15.) Id. at 178-80. Not surprisingly, Johnson, who had no college degree, initially was seen as playing a subordinate rote to Masters, a prominent physician and faculty member at Washington University School of Medicine. See infra notes 92 93 and accompanying text. As their work gained world wide acclaim, however, Johnson's stature grew. So, for example, in 1970 they shared the cover of Time Magazine. See Dr. William Masters and Virginia Johnson, TIME, http://www.time.com/time/covers/0,16641,19700525,00.html (last visited Feb. 15, 2011); MAIER, supra note 11, at 211.

(16.) MAIER, supra note 11, at 95-102, 156.

(17.) As noted, Masters and Johnson coined this term. Id. at 179.

(18.) See id.; see also WILLIAM H. MASTERS & VIRGINIA E. JOHNSON, HUMAN SEXUAL RESPONSE (1966) [hereinafter MASTERS & JOHNSON, HUMAN SEXUAL RESPONSE]; WILLIAM H. MASTERS & VIRGINIA E. JOHNSON, HUMAN SEXUAL INADEQUACY (1970) [hereinafter MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY].

(19.) MAIER, supra note 11, at 87-92, 235-36; see also supra note 15.

(20.) MAIER, supra note 11, at 103.

(21.) Id. at 104-07.

(22.) Id. at 178-80.

(23.) Id. at 180-84.

(24.) As Maier explains, the term "sensate focus" refers to
   a series of touching exercises conducted outside the clinic,
   usually in the couple's home or a hotel room, aimed at restoring
   intimacy between them. Particularly for women, the sensate focus
   exercises--with no immediate demands of intercourse allowed many to
   reacquaint themselves with their natural sensuousness. So many
   patients had been taught that sex was wrong that it rendered them
   unable to make love in a mature or even adequate way.


Id. at 181; see also MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18, at 146-54.

(25.) MAIER, supra note 11, at 196-202. Indeed, Masters and Johnson explained that "it is against Foundation policy to treat the sexually dysfunctional individual as a single entity." MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18, at 148.

(26.) MAIER, supra note 11, at 177-80.

(27.) Id. at 176-84. This notion of standpoint has a theoretical counterpart in positionality, as elaborated by Kate Bartlett, for example. See Katharine T. Bartlett, Feminist Legal Methods, 103 HARV. L. REV. 829, 880-87 (1990).

(28.) In their initial research and therapeutic interventions, they worked with presumably heterosexual couples. See MAIER, supra note 11, at 103-14, 176-84.

(29.) Id. at 176-84.

(30.) MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18, at v ("It is to be hoped that human sexual inadequacy, both the entity and this book, will be rendered obsolete in the next decade. We would like to contribute to the project.").

(31.) See RALPH E. MORROW, WASHINGTON UNIVERSITY IN ST. LOUIS: A HISTORY (1996).

(32.) While studies have shown that 47 percent of couples coming for relationship therapy present with sexual problems, K. Daniel O'Leary, Couple Therapy and Physical Aggression, in CLINICAL HANDBOOK OF COUPLE THERAPY 478, 480 (Alan S. Gurman ed., 4th ed. 2008), few graduate schools offer coursework or practicum experiences to prepare either psychologists or clinical social workers to address these problems competently. Michele Harway's Handbook of Couples Therapy includes no chapter on the role of sex in marriage and no chapter outlining how couples therapists might treat sexual issues beyond infidelity. See HANDBOOK OF COUPLES THERAPY (Michele Harway ed., 2005). Likewise, John M. Gottman, of "love clinic" fame, downplays the role of sexual problems in relationship problems in his books. In the seven questions he says he asks clients, there is not one that asks them about the quality or problems in their sex lives. See JOHN M. GOTTMAN, THE MARRIAGE CLINIC: A SCIENTIFICALLY-BASED MARITAL THERAPY 119-28 (1999). Barry McCarthy, a prolific author of contemporary sex therapy monographs and articles, notes with regret the lack of opportunity for family and couples practitioners-in-training to learn sex therapy skills, knowledge, and attitudes: "Traditionally, couple therapy has underplayed the importance of sexuality." Barry W. McCarthy, L. Elizabeth Bodnar & Mitsouko Handal, Integrating Sex Therapy and Couple Therapy, in THE HANDBOOK OF SEXUALITY IN CLOSE RELATIONSHIPS 573, 573 (John H. Harvey, Amy Wenzel & Susan Sprecher eds., 2004). While Gerald Weeks calls for sex therapists to integrate couples therapy perspectives in their practices, Gerald R. Weeks, The Emergence o[ a New Paradigm in Sex Therapy: Integration, 20 SEXUAL & RELATIONSHIP THERAPY 89 (2005), couples therapists do not seem to feel as comfortable integrating sex therapy into couples therapy. See Tina M. Timm, "Do I Really Have to Talk About Sex?" Encouraging Beginning Therapists to Integrate Sexuality into Couples Therapy, 8 J. COUPLE & RELATIONSHIP THERAPY 15 (2009). Tina Timm, a professor of Family Therapy at Michigan State University and author of numerous articles advancing the integration of sex therapy in couples therapy, points out that a review of the standards of the Council on Social Work Education (CSWE) and the American Psychological Association (APA) reveals no required content on sexuality:
 Although the Commission on Accreditation for Marriage and Family
 Therapy Education (COAMFTE) Standards of Accreditation Version 10.3
 requires accredited programs to include "content on issues of
 gender and sexual functioning, sexual orientation, and sex therapy
 as they relate to couple, marriage and family therapy theory and
 practice," the depth of this content can vary a great deal from
 program to program.


Id. at 17. Timm further points out, "Psychiatrists also admit they are too embarrassed to mention sexuality or inquire about sexual problems in consultations with patients, fearing that they might be misunderstood or that such questions might be upsetting ... [and] only 24% of trainee psychiatrists reported to routinely ask patients about their psychosexual history." Id. at 17 (citing K. Rele & K. Wylie, Management of Psychosexual and Relationship Problems in General Mental Health Services by Psychiatry Trainees, 61 INT'L J. CLINICAL PRAC. 1701 (2007)).

We do not mean to suggest that sexual issues are never included in couples therapy. Journalist Laurie Abraham reports on a sex revitalization weekend included in the therapy of the couples group she followed and described. LAURIE ABRAHAM, THE HUSBANDS AND WIVES CLUB: A YEAR IN THE LIFE OF A COUPLES THERAPY GROUP 26-44 (2010). Tara Parker-Pope cites unnamed therapists who prescribe sex twice a week to "improve your mood, make you more patient, damp down anger, and lead to a better, more contented relationship." TARA PARKER-POPE, FOR BETTER: THE SCIENCE OF A GOOD MARRIAGE 286 (2010). Such practices do not represent an integration of sex therapy into couples therapy, but, rather, an add-on approach to couples therapy.

(33.) See MAIER, supra note 11, at 331-38.

(34.) Maier does note the rise of Viagra. Id. at 357-58.

(35.) Press Release, Boehringer Ingelheim, supra note 3.

(36.) See MAIER, supra note l 1, at 157.

(37.) MASTERS & JOHNSON, HUMAN SEXUAL RESPONSE, supra note 18, at 135. On the gendered "'orgasm gap," see, for example, MARCIA DOUGLASS & LISA DOUGLASS, THE SEX YOU WANT: A LOVERS' GUIDE TO WOMEN'S SEXUAL PLEASURE 1 38 (2002); ELISABETH A. LLOYD, THE CASE OF THE FEMALE ORGASM: BIAS IN THE SCIENCE OF EVOLUTION 21-43 (2005).

(38.) See Susan Ekberg Stiritz, Cultural Cliteracy: Exposing the Contexts of Women's Not Coming, 23 BERKELEY J. GENDER L. & JUST. 243 (2008).

(39.) In their second book, Human Sexual Inadequacy, Masters and Johnson describe the intensive treatments they administered to 510 marital units, with each treatment lasting two weeks at their St. Louis clinic. MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18, at 353-55; see Brian Daines & Ruth Hallam-Jones, Multifaceted Intervention Sex Therapy (MIST), 22 SEXUAL & RELATIONSHIP THERAPY 339, 340 (2007).

(40.) Daines & Hallam-Jones, supra note 39, at 340.

(41.) See ROSS MORROW, SEX RESEARCH AND SEX THERAPY: A SOCIOLOGICAL ANALYSIS OF MASTERS AND JOHNSON 3, 163 (2008); see also Leonard R. Derogatis, Jon K. Meyer & Katherine M. King, Psychopathology in Individuals with Sexual Dysfunction, 138 AM. J. PSYCHIATRY 757 (1981).

(42.) See MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18, at 367 tbl.12.

(43.) MORROW, supra note 41, at 3.

(44.) Id.; see also THOMAS KUHN, THE STRUCTURE OF SCIENTIFIC REVOLUTIONS 43-51 (3d ed. 1966). Present-day practices date specifically from the 1970 publication of Masters and Johnson's second book, Human Sexual Inadequacy. See MORROW, supra note 41, at 3.

(45.) MAIER, supra note 11, at 252-59.

(46.) See Dr. William Masters and Virginia Johnson, supra note 15.

(47.) See, e.g., Leonore Tiefer, The Viagra Phenomenon, 9 SEXUALITIES 273, 279-82 (2006); see also LOVE AND OTHER DRUGS (Twentieth Century Fox 2010) (film showing how pharmaceutical companies market and promote their products, including Viagra).

(48.) See MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18.

(49.) See supra notes 3-4 and accompanying text; McCarthy, Bodnar & Handal, supra note 32, at 590.

(50.) Biography: Masters and Johnson: The Science of Sex (A&E Network television broadcast 1996).

(51.) See Ken Plummer Symbolic Interactionism and Sexual Conduct: An Emergent Perspective, in SEXUALITY AND GENDER 20 (Christine L. Williams & Arlene Stein eds., 2002). In a statement with which we agree, Plummer points out:
   [The] starting point in the study of human sexuality challenges
   much of our contemporary wisdom about sex; whereas many presume to
   know what sex is, interactionists do not; whereas it is commonly
   sensed as something special, interactionists put it on a par with
   everything else; whereas it is commonly sensed as being either in
   need of repression or as a potential source of liberation,
   interactionists see it as merely reflecting cultural expectations;
   whereas it is commonly seen as being the motive force for much
   human behaviour, interactionists invert this wisdom and
   suggest that sex is engaged in tar wider social reasons; whereas
   "too much' or "too little' sex are frequently seen as problems,
   interactionists see no reason for this; whereas sexual development
   is usually seen to be determined by childhood experience,
   interactionists see it as much more fluid and changing; whereas
   certain patterns of sexual development can be assumed as
   'perversions', the interactionists see these critically as social
   constructions. The interactionist is a stranger to contemporary
   cultural meanings and concocts a heretical view.


Id. at 30.

(52.) Thomas W. Laqueur, Sexuality, and the Transformation of Culture: The Longue Duree, 12 SEXUALITIES 418, 420 (2009) ("[Although] there are turning points in the history of things, ... the sexual body is recognizable as a ground for the making of culture over very long periods of time.").

(53.) The American Association of University Professors honored Shepley in 1959, when it made him the second recipient of its Alexander Meiklejohn Award for Academic Freedom. Alexander Meiklejohn Award for Academic Freedom, AM. ASS'N U. PROFESSORS, http://www.aaup.org/AAUP/about/awards/meiklejohn.htm (last visited Feb. 15, 2011).

(54.) MAIER, supra note 11, at 66-75. Masters also secured the cooperation of the local police chief and, with Shepley's encouragement, the Archbishop of St. Louis. Id. at 76-78.

(55.) See, e.g., Keyishian v. Bd. of Regents, 385 U.S. 589 (1966); Sweezy v. New Hampshire, 354 U.S. 234 (1957); Adler v. Bd. of Educ., 342 U.S. 485 (1952) (Black, J., dissenting); see also MAIER, supra note 11, at 66.

(56.) DEBORAH CADBURY, SPACE RACE: THE EPIC BATTLE BETWEEN AMERICA AND THE SOVIET UNION FOR DOMINION OF SPACE 166, 268 (2006).

(57.) See MAIER, supra note 11, at 47-56, 79.

(58.) SIMONE DE BEAUVOIR, THE SECOND SEX 167 (1957).

(59.) DAVID ALLYN, MAKE LOVE, NOT WAR: THE SEXUAL REVOLUTION: AN UNFETTERED HISTORY 33 (2000).

(60.) Id. at 250.

(61.) BETTY FRIEDAN, LIFE SO FAR: A MEMOIR 207 (2000).

(62.) GERMANE GREER, THE FEMALE EUNUCH (1970).

(63.) Judith Weinraub, Germaine Greer--Opinions That May Shock the Faithful, N.Y. TIMES, Mar. 22, 1971, http://www.nytimes.com/books/99/05/99/specials/greer-shock.html?_r=l (quoting Germaine Greer); see also Audre Lorde, The Uses of the Erotic: The Erotic as Power, in BLACK FEMINIST CULTURAL CRITICISM 285, 285 (Jacqueline Bobo ed., 2001) (noting that women's erotic power has been suppressed, "vilified, abused, and devalued in western society").

(64.) See BETTY FRIEDAN, THE FEMININE MYSTIQUE (1963).

(65.) SHULAMITH FIRESTONE, THE DIALECTIC OF SEX: THE CASE FOR FEMINIST REVOLUTION 8-15 (1970).

(66.) KATE MILLETT, SEXUAL POLITICS (1970).

(67.) SISTERHOOD IS POWERFUL: AN ANTHOLOGY OF WRITINGS FROM THE WOMEN'S LIBERATION MOVEMENT (Robin Morgan ed., 1970).

(68.) See Anne Koedt, The Myth of the Vaginal Orgasm, in RADICAL FEMINISM: A DOCUMENTARY READER 371 (Barbara A. Crow ed., 2000).

(69.) See supra note 24 and accompanying text.

(70.) CAROL GILLIGAN, IN A DIFFERENT VOICE: PSYCHOLOGICAL THEORY AND WOMEN'S DEVELOPMENT 16-17 (1982).

(71.) See MAIER, supra note 11, at 241-51.

(72.) See Griswold v. Connecticut, 381 U.S. 479 (1965); Eisenstadt v. Baird, 405 U.S. 438 (1972).

(73.) Roe v. Wade, 410 U.S. 113 (1973); Doe v. Bolton, 410 U.S. 179 (1973).

(74.) Eisenstadt, 405 U.S. at 448 (reasoning that pregnancy and birth constitute disproportionate punishments for the misdemeanor of fornication).

(75.) See, e.g., Sylvia A. Law, Rethinking Sex and the Constitution, 132 U. PA. L. REV. 955 (1984); Reva Siegel, Reasoning from the Boo(v: A Historical Perspective on Abortion Regulation and Questions of Equal Protection, 44 STAY. L. REV. 261 (1992); see also Susan Frelich Appleton, Doctors. Patients and the Constitution: A Theoretical Analysis of the Physician's Role in "Private" Reproductive Decisions, 63 WASH. U. L.Q. 183, 187 (1985).

(76.) Nguyen v. INS, 533 U.S. 53, 76 (2001) (O'Connor, J., dissenting).

(77.) Taylor v. Louisiana, 419 U.S. 522 (1975).

(78.) Miss. Univ. for Women v. Hogan, 458 U.S. 718 (1982); see also United States v. Virginia, 518 U.S. 575 (1996) (disallowing male-only access to elite state-operated military academy).

(79.) Orr v. Orr, 440 U.S. 268 (1979) (invalidating Alabama's statutory scheme imposing alimony obligations on husbands but not wives); Kirchberg v. Feenstra, 450 U.S. 455 (1981) (invalidating Louisiana's statutory scheme giving husbands unilateral control over jointly owned community property).

(80.) See, e.g., LENORE J. WEITZMAN, THE DIVORCE REVOLUTION: THE UNEXPECTED SOCIAL AND ECONOMIC CONSEQUENCES FOR WOMEN AND CHILDREN IN AMERICA 70-109 (1985); cf. Richard R. Peterson, A Re-Evaluation of the Economic Consequences" of Divorce, 61 AM. SOC. REV. 528 (1996) (challenging the analysis and statistics in The Divorce Revolution).

(81.) See, e.g., Elizabeth M. Schneider, The Violence of Privacy, 23 CONN. L. REV. 973 (1991) (examining how privacy permits and encourages family violence).

(82.) NANCY D. POLIKOFF, BEYOND (STRAIGHT AND GAY) MARRIAGE: VALUING ALL FAMILIES UNDER THE LAW 126-27 (2008).

(83.) See, e.g., Bradwell v. Illinois, 83 U.S. 130, 141 (Bradley, J., concurring) ("The constitution of the family organization, which is founded in the divine ordinance, as well as in the nature of things, indicates the domestic sphere as that which properly belongs to the domain and functions of womanhood."); Prince v. Massachusetts, 321 U.S. 158, 166 (1944) (recognizing "the private realm of family life which the state cannot enter").

(84.) See, e.g., Frances E. Olsen, The Myth of State Intervention in the Family, 18 U. MICH. J.L. REFORM 835 (1985).

(85.) See, e.g., Schneider, supra note 81, at 974 ("The concept of marital privacy ... historically has been the key ideological rationale for state refusal to intervene to protect battered women....").

(86.) See MARTHA ALBERTSON FINEMAN, THE AUTONOMY MYTH: A THEORY OF DEPENDENCY 44-53 (2004).

(87.) See, e.g., Linda C. McClain, The Poverty of Privacy?, 3 COLUM. J. GENDER & L. 119, 136-38 (1992).

(88.) See, e.g., Shana Alexander, Coming Out of the Closet, NEWSWEEK, Feb. 3, 1975.

(89.) See, e.g., Lawrence v. Texas, 539 U.S. 558 (2003).

(90.) See Olsen, supra note 84, at 857 n.57.

(91.) See, e.g., ALAN JAY LERNER & FREDERICK LOEWE, CAMELOT (1960).

(92.) See MATER, supra note 11, at 215.

(93.) For example, one might well regard Johnson as a possible victim of sexual harassment, exploited by Masters, given the workplace setting in which their personal relationship developed--from affair to marriage to subsequent divorce--and Johnson's ongoing dependence on Masters for her job. See id. at 147, 231-38, 338.

(94.) See id at 134-40.

(95.) Id.

(96.) See id

(97.) Id. at 141.

(98.) LEONORE TIEFER, Doing the Viagra Tango: Sex Pill as Symbol arm Substance, in SEX IS NOT A NATURAL ACT AND OTHER ESSAYS 107, 107 (2d ed. 2004).

(99.) See supra note 9 and accompanying text. For discussions of neoliberal ideology and rhetoric, including the characteristics listed in the text, see, for example, Luc BOLTANSKI & EVE CHIAPELLO, THE NEW SPIRIT OF CAPITALISM (2006); COULDRY, supra note 9; Barry D. Adam, Constructing the Neoliberal Sexual Actor: Responsibility and Care of the Self in the Discourse of Barebackers, 7 CULTURE, HEALTH & SEXUALITY 333,339, 344-45 (2005); Lynne Layton, Who's Responsible? Our Mutual Implication in Each Other's Suffering, 19 PSYCHOANALYTIC DIALOGUES 105 (2009); Martha T. McCluskey, How Queer Theory Makes Neoliberalism Sexy, in FEMINIST AND QUEER LEGAL THEORY: INTIMATE ENCOUNTERS, UNCOMFORTABLE CONVERSATIONS 115, 126-27 (Martha Albertson Fineman, Jack E. Jackson & Adam P. Romero eds., 2009).

(100.) See, e.g., Reno v. ACLU, 521 U.S. 844, 885 (1997); see also DAVID L. KIRP, SHAKESPEARE, EINSTEIN AND THE BOTTOM LINE: THE MARKETING OF HIGHER EDUCATION (2004).

(101.) See, e.g., Ingo Liefner, Funding, Resource Allocation, and Performance in Higher Education Systems, 46 HIGHER EDUC. 469, 469-70 (2003); Carlo Salerno, Public Money and Private Providers: Funding Channels and National Patterns in Four Countries, 48 HIGHER EDUC. 101, 120-24 (2004) (using Pennsylvania as a comparative example).

(102.) See generally Office of the Vice Chancellor for Research, Annual Report: Fiscal Year 2009, WASH. U. IN ST. LOUIS, (Feb. 15, 2010), http://research.wustl.edu/Documents/Annual%20Reports/FY09AnnualReport.pdf.

(103.) See Office of the Vice Chancellor for Research, Guide to Fed. Agency Reporting Requirements, WASH. U. IN ST. Louis, (Apr. 2008), http://wuro.wustl.edufPoliciesProcedures/FedReportingGuide.pdf: James D. Clements, Improving Bayh-Dole: A Case for Inventor Ownership of Federally Sponsored Research Patents', 49 IDEA 469 (2009); see also Bd. of Trs. of Leland Stanford Junior Univ. v. Roche Molecular Sys., Inc., 583 F.3d 832 (9th Cir. 2009), cert. granted, 131 S. Ct. 502 (2010) (dispute about ownership of invention by university employee under federally funded research).

(104.) See, e.g., Faculty Information 2010, WASH. U. IN ST. LOUIS, H79-83 (Jan. 2010), http ://provost.wustl.edu/sites/provost, wustl.edu/files/ imce/FacultyHandbook2010.pdf.

(105.) See Ernst Benjamin, Some Implications of Tenure for the Profession and Society, AAUP, http://www.aaup.org/AAUP/issues/tenure/benjamintenureimps.htm (last visited Feb. 19, 2011).

(106.) Purview of Institutional Review Boards Increasing, ACADEME, Nov.-Dec. 2000, at 15, available at http://www.aaup.org/AAUP/pubsres/academe/2000/ND/AW/irbs.htm.

(107.) Although neoliberalism rejects protective economic regulations, the ideology also borrows from (indeed, assumes) socially conservative views about sex and gender. See, e.g., FINEMAN, supra note 86, at 73-79, 87-92; McCluskey, supra note 99, at 118-19. Thus, research restrictions imposed in the name of sexual privacy are not inconsistent with neoliberal values.

(108.) Tom L. Beauchamp, Ruth R. Faden, R. Jay Wallace, Jr. & LeRoy Walters, Introduction to ETHICAL ISSUES IN SOCIAL SCIENCE RESEARCH 3, 4 (Tom L. Beauchamp, Ruth P. Faden, R. Jay Wallace, Jr. & LeRoy Waiters eds., 1982).

(109.) Symposium, Twenty Years After: The Legacy of the Tuskegee Syphilix Study, HASTINGS CENTER REP., Nov.- Dec. 1992, at 29.

(110.) See Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972); Beauchamp et al., supra note 108, at 5; Lew Margolis, Ethical Principles for Analyzing Dilemmas in Sex Research, 27 HEALTH, EDUC. & BEHAV. 24, 24 (2000).

(111.) See generally Margolis, supra note 110.

(112.) MAIER, supra note 11, at 315.

(113.) Ruth Macklin raises this possibility without necessarily endorsing this position. Ruth Macklin, Masters" & Johnson Call a Conference: Ethics, Sex Research, and Sex Therapy, 6 HASTINGS CENTER REP. 5, 5 (1976).

(114.) Id. at 6.

(115.) Beauchamp et al., supra note 108, at 11-14.

(116.) One committee member protested: "Undergraduates are not able to provide informed consent. They don't know how their participation in such research could haunt them later. Also, what if their parents found out? I wouldn't want to get that phone call." Meeting of Faculty of Women, Gender & Sexuality Studies Program, Washington University in St. Louis, Dec. 18, 2009. The IRB has since allowed students to conduct such interviews and focus groups, with careful monitoring.

(117.) Tiefer, supra note 47, at 281.

(118.) Interview by Susan Appleton with Rebecca Dresser, Daniel Noyes Kirby Professor and Professor of Ethics in Medicine, Washington University School of Law (Mar. 12, 2010).

(119.) Tiefer, supra note 47, at 280.

(120.) TIEFER, supra note 98, at 109.

(121.) Lisa A. Hayden, Gender Discrimination Within the Reproductive Health Care System: Viagra v. Birth Control, 13 J.L. & HEALTH 171 (1999).

(122.) CATHARINE A. MACKINNON, Privacy v. Equality: Beyond Roe v. Wade (1983), in FEMINISM UNMODIFIED: DISCOURSES ON LIFE AND LAW 93 (1987); see also Susan Frelich Appleton, Toward a "Culturally Cliterate '" Family Law?, 23 BERKELEY J. GENDER L. & JUST. 267, 334-35 (2008).

(123.) MA1ER, supra note 11, at 357-59; see also ABRAHAM MORGENTALER, THE VIAGRA MYTH: THE SURPRISING IMPACT ON LOVE AND RELATIONSHIPS (2003).

(124.) Former U.S. Senator and presidential candidate Bob Dole served as a spokesperson for Viagra. See, e.g., Jane Brody, Can Bob Dole Save Your Life? Ask Your Doctor, N.Y. TIMES, Apr. 26, 2005, at F11; see also Chris Conway, Viagra," Recalling the Madness, N.Y. TIMES, Mar. 30, 2008, at WK5 (retrospective on tenth anniversary of Viagra's approval by the FDA); Harry Jackson, Jr., Viva Viagra, ST. LOUIS POST-DISPATCH, Mar. 24, 2008, at H1 (same).

(125.) See supra note 32 and accompanying text.

(126.) Carole Stewart, Comment, Mandated Medicaid Coverage of Viagra: Raising the Issues of Questionable Priorities, the Need.['or a Definition of Medical Necessity, and the Politics of Poverty, 44 LOY. L. REV. 611, 612 (1998). See generally Lars Noah, Pigeonholing illness: Medical Diagnosis as a Legal Construct, 50 HASTINGS L.J. 241,258 59 (1999). Such coverage is now excluded under Medicaid and Medicare Part D. See 42 U.S.C. [section] 1396r-8(d)(2)(H) (2011); DEPARTMENT OF HEALTH & HUMAN SERVS., OFFICE OF INSPECTOR GENERAL, REVIEW OF ERECTILE DYSFUNCTION DRUGS IN THE MEDICARE PART D PROGRAM 3, 4 (2011); MEDICARE & MEDICAID GUIDE EXPLANATIONS AND ANNOTATIONS (CCH) ([paragraph]) 14,591 (2011). Under healthcare reform, the Patient Protection Affordable Care Act, the Secretary of Health and Human Services decides what prescription drugs must be covered. See Jessica Mantel, Setting National Coverage Standards for Health Plans Under Healthcare Reform, 58 UCLA L. REV. 221, 229-30 (2010).

(127.) Harris v. McRae, 448 U.S. 297, 316 (1980).

(128.) See. e.g., Ben Adler, Why Did the Obama Administration Ban Most Abortion Coverage in High-Risk Health-Insurance Pools?, NEWSWEEK (July 30, 2010), http://www.newsweek.com/blogs/the-gaggle/2010/07/30/why-did-the-obama- administration-ban-most-abortion-coverage-in-high-risk- health-insurance-pools.html; Ricardo Alonso-Zaldivar, Labeling Birth Control "Preventive Medicine" Could Make Contraception Free for US Women, CHI. TRIB., Oct. 31, 2010, http://chicagotribune.com/health/sns-ap-us-birth-control,0,3088426.story.

(129.) See generally Hayden, supra note 121; Tiefer, supra note 47, at 286-87. See also Sylvia A. Law, Sex Discrimination and Insurance for Contraception, 73 WASH. L. REV. 363 (1998).

(130.) In re Union Pac. R.R. Emp't Practices Litig., 479 F.3d 936, 942, 944-45 (8th Cir. 2007). According to the court below, the plan covered prescription drugs for erectile dysfunction. 378 F. Supp. 2d 1139, 1148 (D. Neb. 2005), rev'd, 479 F.3d 936. But see, e.g., Erickson v. Bartell Drug Co., 141 F. Supp. 2d 1266, 1271 (W.D. Wash. 2001).

(131.) See Gonzales v. Carhart, 550 U.S. 124 (2007); Reva B. Siegel, The Right's Reasons: Constitutional Conflict and the Spread of Woman-Protective Antiabortion Argument, 57 DUKE L.J. 1641, 1690 (2008). In addition, contraception got cut from the federal stimulus package. See Matt Bai, Taking the Hill, N.Y. TIMES, June 2, 2009, [section] 6 (Magazine), at MM30. Congress and President Obama were also willing to let anti-abortion forces have their way to secure healthcare reform. See Patricia Zengerle, Obama Signs Order on Abortion and Healthcare, REUTERS (Mar. 24, 2010, 6:00 PM) http://www.reuters.com/article/idUSTRE62N61Y201003 24.

(132.) Lawrence v. Texas, 539 U.S. 558, 567 (2003); see Laura A. Rosenbury & Jennifer E. Rothman, Sex In and Out of Intimacy, 59 EMORY L.J. 809 (2010); see also JANET HALLEY, SPLIT DECISIONS: HOW AND WHY TO TAKE A BREAK FROM FEMINISM 65 (2006) (criticizing legal feminism for failing to theorize heterosexual women's "love of the cock").

(133.) Compare Reliable Consultants, Inc. v. Earle, 517 F.3d 738, 744 (5th Cir. 2008), with Williams v. Morgan, 478 F.3d 1316 (11th Cir. 2007). See also Kiln Shayo Buchanan, Lawrence v. Geduldig: Regulating Women's Sexuality, 56 EMORY L.J. 1235, 1272-74 (2007); Abby Ellin, Advertising: For Female-Aphrodisiac Makers, Effort at Parity, N.Y. TIMES, Sept. 13, 2010, http://www.nytimes.com/2010/09/14/business/media/14adco.html?scp=1&sq= zestra&st=cse (reporting double standard in obstacles to advertising oils to enhance female pleasure and satisfaction, given pervasive advertisements of Viagra and similar drugs).

(134.) See, e.g., David Segal, A Dose of Desire." The Race Is on to Create "Pink Viagra, " But Some Women Aren't in the Mood for It, WASH. POST, Mar. 12, 2008, at C01 (quoting Leonore Tiefer's criticisms); see also Bergner, supra note 7.

(135.) Katherine M. Franke, Theorizing Yes." An Essay on Feminism, Law, and Desire, 101 COLUM. L. REV. 181 (2001).

(136.) See generally LAURA MARIA AGUSTIN, SEX AT THE MARGINS (2007).

(137.) See generally Andrea Dworkin, Against the Male Flood." Censorship, Pornography, and Equality, 8 HARV. WOMEN'S L.J. 1 (1985).

(138.) See SUSAN FALUDI, BACKLASH: THE UNDECLARED WAR AGAINST AMERICAN WOMEN 320 (1991).

(139.) See, e.g., HALLEY, supra note 132; McCluskey, supra note 99.

(140.) Fantasy, OXFORD ENGLISH DICTIONARY, http://oed.com/view/Entry/68119?rskey= epb76T&result=1&isAdvanced=false# (last visited Mar. 1, 2011).

(141.) Jacob A. Arlow, Unconscious Fantasy and Disturbances of Conscious Experience, 38 PSYCHOANALYTIC Q. 1 (1969); see also SIGMUND FREUD, INTERPRETATION OF DREAMS 118 19, 121 (Basic Books 1960) (1900) ("The dream represented a particular state of affairs as I should have wished it to be.... Thus its content was the fulfilment of a wish and its motive was a wish. When the work of interpretation has been completed, we perceive that a dream is the fulfilment of a wish.").

(142.) HANNA SEGAL, INTRODUCTION TO THE WORK OF MELANIE KLEIN 11-23 (1964) ("Phantasy").

(143.) Jacob A. Arlow, in a classic psychoanalytic article, points out: "[F]antasy activity, conscious or unconscious, is a constant feature of mental life. In one part of our minds we are daydreaming all the time, or at least all the time we are awake and a good deal of the time we are asleep." Arlow, supra note 141, at 5.

(144.) GEORGE LAKOFF & MARK JOHNSON, METAPHORS WE LIVE BY (l 980).

(145.) Arlow, supranote 141, at 7.

(146.) LAKOFF & JOHNSON, supra note 144, at 56.

(147.) GEORGE LAKOFF, WOMEN, FIRE, AND DANGEROUS THINGS: WHAT CATEGORIES REVEAL ABOUT THE MIND 303 (1987).

(148.) Robin Lakoff discusses how women are subordinated by the frames in which language represents them. See Robin Lakoff, Language and Woman's Place, 2 LANGUAGE IN SOC'Y 45 (1973). Here Lakoff reports that her study of how women are taught to use language and how they are represented in language "differs from men's speech.... [B]oth types of phenomena reflect a deep bias on the part of our culture ... against women being accorded full status as rational creatures and individuals in their own right." Id. at 49. In Feminist Criticism in the Wilderness, Elaine Showalter discusses women's particular realities as occupying a "wild zone" of unformulated experience left out of representation in the cultural symbolic. Elaine Showalter, Feminist Criticism in the Wilderness, 8 CRIT. INQUIRY 179, 200 (1981).

(149.) LAKOFF & JOHNSON, supra note 144.

(150.) ETHEL S. PERSON, BY FORCE OF FANTASY 216 (1995) ("[T]he story lines of fantasy ... borrow their narrative content from the cultural surround. Some fantasies are communal at their inception.... Borrowed cultural narratives provide story lines that the fantasizer may not be able to create independently but can adopt as an umbrella for many different wishes and needs."); see also id. at 150, 153.

(151.) Laqueur, supra note 52, at 419-20. Despite Laqueur's emphasis on certain enduring aspects of the sexual body, culture, including law, nonetheless helps shape sex differences that seem "natural." See Mary Joe Frug, Commentary, A Postmodern Feminist Manifesto (An UnfinishedDraft), 105 HARV. L. REV. 1045 (1992).

(152.) See SEGAL, supra note 142: HANNA SEGAL, THE WORK OF HANNA SEGAL: A KLEINIAN APPROACH TO CLINICAL PRACTICE (1990); Melanie Klein, Love, Guilt and Reparation, in LOVE, HATE, AND REPARATION 57 (Melanie Klein & Joan Riviere eds., 1964). For other examples of legal scholarship featuring Klein's work, see, for example, Clare Huntington, Repairing Family Law, 57 DUKE L.J. 1245 (2008); Susan R. Schmeiser, Romancing the Family, 33 HARV. J.L. & GENDER 327, 331-32 (2010).

(153.) For other contemporary efforts to apply psychoanalytic insights beyond the individual, see, for example, LAWRENCE J. BROWN, INTERSUBJECTIVE PROCESSES AND THE UNCONSCIOUS: AN INTEGRATION OF FREUDIAN, KLEINIAN, AND BIONIAN PERSPECTIVES (2011); Elisha Davar, To Whom Does" the Unconscious Belong? The Interface Between the Private and Social Dimension in Psychotherapy Practice, 14 PSYCHODYNAMIC PRAC. 137 (2008); Layton, supra note 99.

(154.) SEGAL, supra note 152, at 186-87.

(155.) Id. at 187-88.

(156.) Id.

(157.) Id

(158.) Id. at 115-17, 188.

(159.) Klein called the less mature perspective "the paranoid schizoid position" and the more mature, integrated approach the "depressive position." SEGAL, supra note 142, at 67-68; SEGAL, supra note 152, at 47 ("Both symbolism and reality testing are developments of the depressive position, in which gradually the external and internal worlds get differentiated.").

(160.) See, e.g., THOMAS L. FRIEDMAN, THE WORLD IS FLAT: A BRIEF HISTORY OF THE TWENTY-FIRST CENTURY (2005).

(161.) In her essay on the stressful effects of living under neoliberalism, Rachel Peltz quotes Robert Reich, who explains how economic priorities affect personal life:
   The benefits of the new economy turn on innovation and the
   increased ease with which buyers can switch to better, faster, and
   cheaper products from anywhere around the world, to
   higher-returning investments, and to the joint amenities that
   constitute the modem community. These same features of the new
   economy are also contributing to financial insecurity, more
   frenzied work, widening gaps in income and wealth, an ever
   efficient sorting mechanism, and the consequent erosion of
   personal, family, and community life.


Rachel Peltz, The Manic Society, in PSYCHOANALYSIS, CLASS AND POLITICS: ENCOUNTERS IN THE POLITICAL SETTING 65, 68 (Lynne Layton, Nancy Caro Hollander & Susan Gutwill eds., 2006) (quoting Robert Reich, The New Economy as a Decent Society, AMERICAN PROSPECT, Feb. 2001, at 22).

(162.) See MAIER, supra note 11, at 176-84.

(163.) See id. at 176 95.

(164.) See JANICE A. RADWAY, READING THE ROMANCE: WOMEN, PATRIARCHY, AND POPULAR LITERATURE (2d ed. 1991); Franke, supra note 135, at 207 (quoting Rebecca Young to present stereotypical characterization of female sexuality as "romantic longing"); see also ERICH SEGAL, LOVE STORY 131 (1970) ("Love means never having to say you're sorry.").

(165.) Even popular culture concedes these roots. See, e.g., Elizabeth Weil, A More Perfect Union, N.Y. TIMES, Dec. 6, 2009, [section] 6 (Magazine), at MM36 (discussing the role of the concept of monogamy in marriage and its roots). For references to scientific evidence of the connection between the infant-caregiver bond and the ideal of romantic love, see LISA M. DIAMOND, SEXUAL FLUIDITY: UNDERSTANDING WOMEN'S LOVE AND DESIRE 224-28 (2008).

(166.) Lorde, supra note 63.

(167.) Peggy Reubens, The Silencing of the Self in Men, 2 J. TRAUMA PRAC. 37 (2003).
   Gender socialization causes "normative traumatization" in many men,
   who live with dissociated ego states that interfere with intimacy,
   and/or with their work lives. The "new psychology of men" outlines
   the traumatic etiology: (a) small boys are pushed to sharply
   disidentify with their mothers; (b) this trauma is repressed due to
   shame; (c) many boys are further traumatized by insufficient
   fathering. This paper expands on this explanation, arguing that it
   is important to add dissociation to our clinical understanding.
   Case examples show how trauma, attachment and gender theories,
   combined with appropriate therapeutic techniques, significantly
   enhance the progress these men are able to make in treatment.


Id.; see Judith V. Jordan, The Relational-Cultural Model: Healing Through Mutual Empathy, 65 BULL. MENNINGER CLINIC 92, 92 ("Relational-cultural theory offers an alternative to traditional theories of psychological development. Whereas traditional theories view mature functioning as characterized by movement from dependence to independence, relational-cultural theory suggests that maturity involves growth toward connection and relationship throughout the life span.").

(168.) For example, a popular film from 1979, Kramer v. Kramer, signaled that feminist fantasies of caring and connection, stemming from mother-child attachment, should include fathers too, KRAMER V. KRAMER (Columbia Pictures 1979), a message also reflected in Supreme Court opinions of the time. See, e.g., Weinberger v. Wiesenfeld, 420 U.S. 636 (1975); Caban v. Mohammed, 441 U.S. 380 (1979).

(169.) See MATER, supra note 11, at 244-46.

(170.) See id. at 176 84.

(171.) See supra text accompanying note 46.

(172.) VIRGINIA SATIR, CONJOINT FAMILY THERAPY 259 (3d ed. 1983) (1964).

(173.) See MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18, at 72; see also WILLIAM H. MASTERS, VIRGINIA E. JOHNSON 84 ROBERT C. KOLODNY, HUMAN SEXUALITY 369 (5th ed. 1995) ("A fundamental belief of this book is that good communication underlies the most pleasurable sexual relationships and that sex is actually a form of communication at an especially intimate level.").

(174.) MAIER, supra note 11, at 185 95. More recent studies reinforce this point. See, e.g., Laurie A. Rudman & Julie E. Phelan, The Interpersonal Power of Feminism: Is Feminism Good for Romantic Relationships?, 57 SEX ROLES 787-99 (2007); Vanessa R. Schick, Alyssa N. Zucker & Laina Y. Bay-Cheng, Safer, Better Sex Through Feminism: The Role of Feminist Ideology in Women's Sexual Well-being, 32 PSYCHOL. WOMEN Q. 225 (2006).

(175.) Most evidence-based practices today assert that equal power between partners is required for satisfactory relationships. See Kathrine Carlson Daniels, Toni Schindler Zimmerman & Stephanie Weiland Bowling, Barriers in the Bedroom: A Feminist Application for Working with Couples, 14 J. FEMINIST FAM. THERAPY 21 (2002); see also Tara ParkerPope, Gay, Unions Shed Light on Gender in Marriage, N.Y. TIMES, June 10, 2008, at F1.

(176.) THEODOOR HENDRIK VAN DE VELDE & MARGARET SMYTH, IDEAL MARRIAGE, ITS PHYSIOLOGY AND TECHNIQUE 101, 121 (Greenwood Press 1980) (1928).

(177.) Id. at 156.

(178.) See John Mordechai Gottman & Julie Schwartz Gottman, Gottman Method Couple Therapy, in CLINICAL HANDBOOK OF COUPLE THERAPY 138, 143 (Alan S. Gurman ed., 4th ed. 2008); Susan M. Johnson, Emotionally Focused Couple Therapy, in CLINICAL HANDBOOK OF COUPLE THERAPY, supra, at 107; Alan S. Gurman, A Framework for the Comparative Study of Couple Therapy." History, Models, and Applications, in CLINICAL HANDBOOK OF COUPLE THERAPY, supra, at 1 ; ROBERT TAIBBI, DOING COUPLE THERAPY: CRAFT AND CREATIVITY IN WORK WITH INTIMATE PARTNERS (2009); DANIEL B. WILE, COUPLES THERAPY: A NONTRADITIONAL APPROACH (1981).

(179.) Gottman & Gottman, supra note 178, at 143.

(180.) Id.; TAIBBI, supra note 178; EVAN STARK, COERCIVE CONTROL: THE ENTRAPMENT OF WOMEN IN PERSONAL LIFE 171 (2007).

(181.) STARK, supranote 180, at 171-72.

(182.) See JENNIFER BAUMGARDNER & AMY RICHARDS, MANIFESTA: YOUNG WOMEN, FEMINISM, AND THE FUTURE 50, 59-61 (2000).

(183.) Id.

(184.) We find compelling Amy Richards's justification, posted on her website, for using the term "feminism" anachronistically:
   Feminism really began as a term in France (feminisme) around the
   end of the 1800s. However, the principals [sic] behind this actual
   term i.e., the struggle for equality-have been around since the
   beginning of the Western world. It came to the U.S. at the
   beginning of the 1900s via an article about a French Suffragist
   named Madeline Pelltier. But it didn't come into popular usage
   until the 1960s or 1970s. At that time, women's liberationist was
   actually the preferred term, but that started to get a bad name, so
   it was abandoned for feminism. Now, that has a bad name. However,
   what this example shows, and what I believe, is that the name is in
   many ways irrelevant because it's what's behind the name, i.e.
   equality, that is frightening to people. Therefore, we should stick
   with the name. Read the work of Nancy Cott for more on the history
   of the word.


Amy Richards, Ask Amy: Feminism, FEMINIST.COM, http://www.feminist.com/askamy/ feminism/fem193.html (last visited Apr. 29, 2011).

(185.) Susan Kent points out:
   Until very recently, historians have tended to characterize the
   women's suffrage campaign in England as an exclusively political
   movement, as merely an attempt on the part of women to share in the
   general enfranchisement that occurred throughout the nineteenth
   century.... In fighting for enfranchisement, suffragists sought no
   less than the total transformation of the lives of women. They set
   out to redefine and recreate, by political means, the sexual
   culture of Britain. Though suffragists repeatedly made this clear
   to the British public--and their opponents did not fail to take
   them at their word--the image of the suffrage campaign as a
   conservative, limited, purely political movement has remained
   intact.


SUSAN KENT, SEX AND SUFFRAGE IN BRITAIN 1860-1914, at 2 (1987). Reva Siegel makes a similar point about the connection between voting rights and family law in the campaign for women's suffrage in the United States, and she documents the erasure of this history. Reva B. Siegel, She the People: The Nineteenth Amendment, Sex Equality, Federalism, and Family, 115 HARV. L. REV. 947 (2002).

(186.) See, e.g., Stiritz, supra note 38.

(187.) See generally LLOYD, supra note 37.

(188.) See Appleton, supra note 122, at 287.

(189.) IRVING KENNETH ZOLA, Tell Me ... Tell Me, in MEANINGFUL RELATIONSHIPS: MOMENTS IN TIME 65 (1997). For other authorities citing the connection between communication and pleasure, consistent with our notion of clitoral fantasy, see JUDITH LEVINE, HARMFUL TO MINORS: THE PERILS OF PROTECTING CHILDREN FROM SEX 195 (2002) ("Outercourse necessitates communication and therefore increases the likelihood of consent. Because outercourse doesn't proceed in a prescribed order, neither partner can predict what the other will come up with or what they might come up with together."); Paula England, Emily Fitzgibbons Shafer & Alison C.K. Fogarty, Hooking Up and Forming Romantic Relationships on Today's College Campuses, in THE GENDERED SOCIETY READER 531, 53 (Michael S. Kimmel & Amy Aronson eds., 3d ed. 2008) (positing that higher rates of women's orgasms come from communication).

(190.) See Annie Potts, Coming, Coming, Gone: A Feminist Deconstruction of Heterosexual Orgasm, 3 SEXUALITIES 55 (2000), for a critique of how expectations for women to orgasm are androcentric. See MARCIA DOUGLASS & LISA DOUGLASS, Orgasm or Bust, in ARE WE HAVING FUN YET? THE INTELLIGENT WOMAN'S GUIDE TO SEX (1997), for a critique of those who would marginalize the importance of orgasm in women's sexual repertoires.

(191.) See generally Heinz Lichtenstein, Identity and Sexuality--A Study of Their Interrelationship in Man, 9 J. AM. PSYCHOANALYTIC ASSOC. 179 (1961).

(192.) HALLEY, supra note 132, at 153 (quoting Leo Bersani, Is the Rectum a Grave?, in AIDS: CULTURAL ANALYSIS/CULTURAL ACTIVISM 197, 217 (Douglas Crimp ed., 1988)).

(193.) PEGGY ORENSTEIN, FLUX: WOMEN ON SEX, WORK, LOVE, KIDS, & LIFE IN A HALFCHANGED WORLD 24 (2001).

(194.) RACHEL P. MAINES, THE TECHNOLOGY OF ORGASM: "HYSTERIA," THE VIBRATOR, AND WOMEN'S SEXUAL SATISFACTION 112 (1999).

(195.) Id. at 1.

(196.) Id. at 54-55, 60.

(197.) Id. at 20.

(198.) See, e.g., HANNAH S. DECKER, FREUD, DORA, AND VIENNA 1900 (1991).

(199.) MAINES, supra note 194, at 23.

(200.) Id. at 23, 32, 37.

(201.) Id. at 21-47, 111-23.

(202.) Id. at 24.

(203.) Id. at 1,31 32.

(204.) Id. at 37 38.

(205.) Id. at 91.

(206.) Id. at 99, 114.

(207.) Id. at 115; see also id. at 60-61.

(208.) E.g., Nancy Tuana, Coming to Understand." Orgasm and the Epistemology of Ignorance, 19 HYPATIA 194, 195 (2004) (contending that ignorance of women's sexual pleasure "should not be theorized as a simple omission or gap but is ... an active production ... linked to issues of cognitive authority").

(209.) The instructions for arranging the stage state: "Next to the living room, a private doctor's room, otherwise known as an operating theater." RUHL, supra note 2, at 5.

(210.) See supra note 2 and accompanying text.

(211.) See Nancy Mann Kulish, The Mental Representation of the Clitoris: The Fear of Female Sexuality, 11 PSYCHOANALYTIC INQUIRY 511, 511-15 (1991).

(212.) See id. For another point of view, see Stiritz, supra note 38.

(213.) Paula Bennett, Critical Clitoridectomy: Female Sexual Imagery and Feminist Psychoanalytic Theory, 18 SIGNS 235, 236 (1993).

(214.) Id.

(215.) Stiritz, supra note 38.

(216.) Kathleen McKenna, The Language of Orgasm, in RE: READING, RE: WRITING, RE: TEACHING VIRGINIA WOOLF: SELECTED PAPERS FROM THE FOURTH ANNUAL CONFERENCE ON VIRGINIA WOOLF 29, 29 (Eileen Barrett & Patricia Cramer eds., 1995).

(217.) Carolee Schneemann, The Obscene Body/Politic, 50 ART J. 28 (1991).

(218.) See generally Isabel Coello, Female Genital Mutilation: Marked by Tradition, 7 CARDOZO J. INT'L & COMP. L. 213 (1999) (examining the role of tradition in female genital mutilation); Emanuela Finke, Commentary, Genital Mutilation as an Expression of Power Structures: Ending FGM through Education, Empowerment of Women and Removal of Taboos, 10 AFRICAN J. REPRODUCTIVE HEALTH 13 (2006) (discussing the practice of female genital mutilation as an expression of power and patriarchal control).

(219.) See SHERE HITE, THE HITE REPORT: A NATIONWIDE STUDY ON FEMALE SEXUALITY (1976) [hereinafter HITE, THE HITE REPORT]; SHERE HITE, WOMEN AS REVOLUTIONARY AGENTS OF CHANGE: THE HITE REPORTS AND BEYOND 3 (1994) [hereinafter HITE, WOMEN AS REVOLUTIONARY AGENTS OF CHANGE].

(220.) See BRENDA COSSMAN, SEXUAL CITIZENS: THE LEGAL AND CULTURAL REGULATION OF SEX AND BELONGING 34-35 (2007).

(221.) See BETTY DODSON, SEX FOR ONE: THE JOY OF SELFLOVING (1995); BETTY DODSON PRESENTS ORGASMIC WOMEN: 13 SELFLOVING DIVAS (Betty Dodson 2006).

(222.) Interview by Susan Stiritz with Virginia Johnson, in St. Louis, Mo. (Sept. 5, 2009).

(223.) Williams v. Pryor, 220 F. Supp. 2d 1257, 1297 (N.D. Ala. 2002), rev'd & remanded, Williams v. Att'y Gen., 378 F.3d 1232 (11th Cir. 2004), cert. denied sub nom. Williams v. King, 543 U.S. 1152 (2005), subsequent summary judgment for defendants aff'd, Williams v. Morgan, 478 F.3d 1316 (11th Cir. 2007).

(224.) See David A.J. Richards, Sexual Autonomy and the Constitutional Right to Privacy." A Case Study in Human Rights and the Unwritten Constitution, 30 HASTINGS L.J. 957, 1002 (1979) ("[F]or humans to experience sex is never, even in solitary masturbation, a purely physical act, but is embued with complex evaluational interpretations of its real or fantasied object, often rooted in the whole history of the person from early childhood on.").

(225.) See supra note 37 and accompanying text.

(226.) For an ultimately unsuccessful constitutional challenge to Alabama's ban on the distribution of such devices, see Williams, 220 F. Supp. 2d 1257, rev'd & remanded, Williams v. Att'y Gen., 378 F.3d 1232 (11th Cir. 2004), cert. denied sub nom. Williams v. King, 543 U.S. 1152 (2005), subsequent summary judgment for defendants aff'd, Williams v. Morgan, 478 F.3d 1316 (11th Cir. 2007).

(227.) Interview with Virginia Johnson, supra note 222.

(228.) See MARTY KLEIN & RIKI ROBBINS, LET ME COUNT THE WAYS: DISCOVERING GREAT SEX WITHOUT INTERCOURSE (1999).

(229.) JOHN H. GAGNON, HUMAN SEXUALITIES 1 (1977).

(230.) See MAIER, supra note 11, at 162; Potts, supra note 190.

(231.) See, e.g., BETTY DODSON, ORGASMS FOR TWO: THE JOY OF PARTNERSEX (2002).

(232.) See HELEN REDDY, I Am Woman, on I AM WOMAN (Capitol Records 1971).

(233.) Bridget Crawford, Toward a Third-Wave Feminist Theory: Young Women, Pornography and the Praxis of Pleasure, 14 MICH. J. GENDER & L. 99, 122 (2007).

(234.) R.W. CONNELL, GENDER AND POWER 78 (2d ed. 2005); Michael S. Kimmel, Masculinity as Homophobia: Fear, Shame, and Silence in the Construction of Gender Identity, in THEORIZING MASCULINITIES 119, 125-26 (Harry Brod & Michael Kaufman eds., 1994).

(235.) See Reubens, supra note 167, for another corroborating account of how adopting masculinity inflicts trauma on the young male.

(236.) Kimmel, supra note 234, at 126.

(237.) Id. at 127.

(238.) Id. at 129.

(239.) Id.

(240.) Id. at 131.

(241.) E.g., MITE, THE HITE REPORT, supra note 219; HITE, WOMEN AS REVOLUTIONARY AGENTS OF CHANGE, supra note 219; Koedt, supra note 68; Mary Jane Sherfey, The Evolution and Nature of Female Sexuality in Relation to Psychoanalytic Theory, 14 J. AM. PSYCHOANALYTIC ASS'N 28 (1966).

(242.) ADRIENNE RICH, DREAM OF A COMMON LANGUAGE AND OTHER POEMS (1993).

(243.) See ALFRED C. KINSEY, WARDELL B. POMEROY, CLYDE E. MARTIN & PAUL H. GEBHARD, SEXUAL BEHAVIOR IN THE HUMAN FEMALE (1953); HITE, THE HITE REPORT, supra note 219; HITE, WOMEN AS REVOLUTIONARY AGENTS OF CHANGE, supra note 219; Edward O. Laumannn et al., A Cross-National Study of Subjective Sexual Well-Being Among Older Women and Men: Findings from the Global Study of Sexual Attitudes and Behaviors, 35 ARCHIVES SEXUAL BEHAV. 145 (2006).

(244.) Laumann et al., supra note 243, at 158; see also supra notes 175-85 and accompanying text. But see, e.g., CRISTINA NEHRING, A VINDICATION OF LOVE: RECLAIMING ROMANCE FOR THE TWENTY-FIRST CENTURY 79 (2009) ("It is precisely equality that destroys our libidos, equality that bores men and women alike....").

(245.) Laumann et al., supra note 243, at 155; see also Constance T. Gager & Scott T. Yabiku, Who Has the Time? The Relationship Between Household Labor Time and Sexual Frequency, 31 J. FAM. ISSUES 135, 151 (2010) ("For both men and women, greater time spent doing household labor is associated with higher sexual frequency.").

(246.) See Plummer, supra note 51, at 23.

(247.) See Stiritz, supra note 38; Appleton, supra note 122.

(248.) MAIER, supra note 11, at 68.

(249.) See generally Leonore Tiefer, Sex Therapy as a Humanistic Enterprise, 21 SEXUAL & RELATIONSHIP THERAPY 359 (2006).

(250.) MASTERS & JOHNSON, HUMAN SEXUAL RESPONSE, supra note 18, at 4.

(251.) Leonore Tiefer, Towards a Feminist Sex Therapy, 19 WOMEN & THERAPY 53 (1996); see also MORROW, supra note 41, at 97.

(252.) See generally MASTERS & JOHNSON, HUMAN SEXUAL RESPONSE, supra note 18; MASTERS & JOHNSON, HUMAN SEXUAL INADEQUACY, supra note 18.

(253.) SIGMUND FREUD, Femininity, in NEW INTRODUCTORY LECTURES ON PSYCHOANALYSIS, 139, 157-58 (James Strachey ed. & trans., W.W. Norton & Co. standard ed. 1990) (1932).

(254.) See MAIER, supra note 11, at 237 ("Soon after their wedding, Bill told a reporter about the simple pleasure of hugging in bed after a long day. As Gini declared: 'The concept of sexuality as a question of only the penis in the vagina is so absolutely Victorian it's sick.'").

(255.) Interview with Virginia Johnson, supra note 222.

(256.) LEONORE TIEFER, Historical, Scientific, Clinical, and Feminist Criticisms of "The Human Sexual Response Cycle" Model, in SEX IS NOT A NATURAL ACT AND OTHER ESSAYS, supra note 97, at 41, 43-44 (1995).

(257.) MAIER, supra note 11, at 112.

(258.) Alan Riley, The Role of the Partner in Erectile Dysfunction and its' Treatment, 14 INT'L J. IMPOTENCE RES. (Supp. 1) S105, S106 (2002).

(259.) Annie Potts, Nicola Gavey, Victoria M. Grace & Tiina Vares, The Downside of Viagra: Women's Experiences and Concerns, 25 SOC. HEALTH & ILLNESS 697, 70-05 (2003).

(260.) Id.

(261.) See Riley, supra note 258, at S106 (citing other studies); see also Potts et al., supra note 259, at 705.

(262.) See supra note 37 and accompanying text.

(263.) See Bennett, supra note 213.

(264.) See GAGNON, supra note 229.

(265.) See supra notes 197-201 and accompanying text.

(266.) See AM. PSYCHIATRIC ASS'N, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (3d ed. 1980).

(267.) See supra note 159 and accompanying text.

(268.) See, e.g., JESSICA BENJAMIN, THE BONDS OF LOVE: PSYCHOANALYSIS FEMINISM, AND THE PROBLEM OF DOMINATION 85 (1988).

(269.) See CONNELL, supra note 234 (developing notion of "hegemonic masculinity"); R.W. Connell & James W. Messerschmidt, Hegemonic Masculinity: Rethinking the Concept, 19 GENDER & SOC'Y 829 (2005).

(270.) Meika Loe, Fixing Broken Masculinity: Viagra as A Technology for the Production of Gender and Sexuality, 5 SEXUALITY & CULTURE 97, 104 (2001).

(271.) MASTERS & JOHNSON, HUMAN SEXUAL RESPONSE, supra note 18.

(272.) MAIER, supra note 11, at 357-59; see MORGENTALER, supra note 123.

(273.) See supra notes 24-25 and accompanying text.

(274.) See Sylvie Aubin, Julia R. Heiman, Richard E. Berger, A.V. Murallo & Liu Yung-Wen, Comparing Sildenafil Alone vs. Sildenafil Plus Brief Couple Sex Therapy on Erectile Dysfunction and Couples' Sexual and Marital Quality of Life: A Pilot Study, 35 J. SEX & MARITAL THERAPY 122 (2009). Note: these are sex therapists, not couples therapists.

(275.) See MARTHA C. NUSSBAUM, WOMEN AND HUMAN DEVELOPMENT: THE CAPABILITIES APPROACH (2000) (conceptualizing social justice as the fair distribution of capabilities); see also MARTHA C. NUSSBAUM, THE FRONTIERS OF JUSTICE (2007).

(276.) See Daniels et al., supra note 175; see also Plummet, supra note 51, at 22 (examining the metaphor of the "script," given that sexual conduct is learned).

(277.) See Plummer, supra note 51, at 23 ("Human sexuality--as opposed to biological functioning only comes to exist once it is embroiled with partners (real or imagined), activities, times, places and reasons defined as sexual.").

(278.) See Sandra R. Leiblum, Sex Therapy Today: Current Issues and Future Perspectives, in PRINCIPLES AND PRACTICE OF SEX THERAPY 3, 12 (Sandra R. Leiblum ed., 4th ed. 2007). Leiblum points out:
   It is rare that any medication completely resolves sexual problems
   as a "stand-alone" intervention. In fact, without concomitant
   psychological treatment, the dropout rate for pharmacotherapy
   generally, and erection problems in particular, is quite high,
   perhaps as great as 40-80%. Failure to assess or treat the
   patient's sexual desire, self-esteem, relationship dissatisfaction,
   or erroneous expectations contributes materially to disuse and
   treatment failure, as does a neglect of follow-up and counseling.
   The otherwise tangible physiological benefits of drug therapy are
   often undermined by high anxiety, inadequate stimulation,
   psychological inhibitions, or simple anger.


Id. at 12 (citations omitted).

(279.) Interview by Susan Appleton with Marc Spindelman, Professor of Law, Moritz College of Law, Ohio State Univ., in St. Louis, Mo. (Sept. 29, 2010).

(280.) For stories of women's complaining about the coital imperative, especially as it relates to partners' taking Viagra, see, for example, Aubin et al., supra note 274; Loe, supra note 270; Meika Loe, Sex and the Senior Woman: Pleasure and Danger in the Viagra Era, 7 SEXUALITIES 303 (2004); Ports, supra note 190; Ports et al., supra note 259; Tiefer, supra note 47; Tiina Vares & Virginia Braun, Spreading the Word, but What Word is That? Viagra and Male Sexuality in Popular Culture, 9 SEXUALITIES 315 (2006).

(281.) Potts et al., supra note 259, at 708.

(282.) Id. at 708-09; Annie Potts, Victoria Grace, Nicola Gavey & Tiina Vares, Viagra Stories: Challenging Erectile Dysfunction, 59 SOC. SCI. & MED. 489, 495 (2004).

(283.) Loe, supra note 270, at 110.

(284.) The emphasis on conjoint or dual therapy leaves no doubt about this conclusion. See supra notes 18-29 and accompanying text.

(285.) Rosenbury & Rothman, supra note 132.

(286.) See, e.g., Elizabeth F. Emens, Monogamy's Law." Compulsory Monogamy and Polyamorous Existence, 29 N.Y.U. REV. L. & SOC. CHANGE 277 (2004).

(287.) See supra notes 3-5 and accompanying text.

(288.) John Bancroft, Sex Therapy Needs Building Not Deconstruction, 38 ARCHIVES SEX. BEHAV. 1028, 1028 (2009).

(289.) See MEIKA LOE, THE RISE OF VIAGRA: HOW THE LITTLE BLUE PILL CHANGED SEX IN AMERICA (2004); Joel Lexchin, Bigger and Better: How Pfizer Redefined Erectile Dysfunction, 3 PLOS MED. 429 (2006), available at http://www.plosmedicine.org/article/info%3Adoi%2F10. 1371%2Fjournal.pmed.0030132.

(290.) See supra notes 126, 130 and accompanying text; see also Rosenbury & Rothman, supra note 132, at 865 n.282. Rosenbury and Rothman state that many insurance plans exclude coverage of sex therapy (which they compare to psychotherapy), although they note one case requiring such treatment when necessitated by the risk of infection from a penile implant, Id. (citing Univ. of Kan. Hosp. v. Titus, 452 F. Supp. 2d 1136, 1151 (D. Kan. 2006)).

(291.) MAINES, supra note 194, at 4.

(292.) Id.

(293.) It's a Sexual Marketing Revolution, AMERICAN PUBLIC MEDIA (May 25, 2007), http://marketplace.publicradio.org/shows/2007/05/25/AM200705255.html; see also COSSMAN, supra note 220, at 82.

(294.) MARK DAVIS, SEX, TECHNOLOGY AND PUBLIC HEALTH 37 (2009). Davis's insight offers a more nuanced understanding of the impact of Viagra than those critiques simply arguing that such drugs have medicalized sex.

(295.) See RAY MOYNIHAN & BARBARA MINTZES, SEX, LIES & PHARMACEUTICALS: HOW DRUG COMPANIES PLAN TO PROFIT FROM FEMALE SEXUAL DYSFUNCTION (2010); ORGASM, INC.: THE STRANGE SCIENCE FEMALE PLEASURE (Chicken and Egg Pictures 2009).

(296.) MICHEL FOUCAULT, THE BIRTH OF THE CLINIC: AN ARCHEOLOGY OF MEDICAL PERCEPTION (Alan Sheridan trans., Routledge 1973) (1963) [hereinafter FOUCAULT, BIRTH OF THE CLINIC]; MICHEL FOUCAULT, DISCIPLINE AND PUNISH: THE BIRTH OF THE PRISON (1977) [hereinafter FOUCAULT, DISCIPLINE AND PUNISH].

(297.) FOUCAULT, BIRTH OF THE CLINIC, supra note 296; FOUCAULT, DISCIPLINE AND PUNISH, supra note 296.

(298.) See, e.g., Plummer, supra note 51.

(299.) See Laqueur, supra note 52.

(300.) See Martha Minow, The Supreme Court, 1986 Term," Foreword: Justice Engendered, 101 HARV. L. REV. 10, 68 (1987) ("Power is at its peak when it is least visible, when it shapes preferences, arranges agendas, and excludes serious challenges from discussion or even imagination."); id. at n.269 (quoting MICHEL FOUCAULT, THE HISTORY OF SEXUALITY 86 (1980)) ("[P]ower is tolerable only on condition that it mask a substantial part of itself. Its success is proportional to its ability to hide its own mechanisms.").

(301.) See Adam, supra note 99; see also McCluskey, supra note 99.

(302.) England et al., supra note 189: Shelly Ronen, Grinding on the Dance Floor: Gendered Scripts and Sexualized Dancing at College Parties, 24 GENDER & SOC. 355 (2010).

(303.) Cf. Franke, supra note 135, at 208 ("Particularly now that we are living in the Viagra years, it would behoove us as legal theorists to pursue strategies that would elevate women's sexual pleasure to the same level as that enjoyed by men.").

(304.) See Viagra Commercial, YOUTUBE (Apr. 24, 2006), http://www.youtube.com/watch? v=Xk9JwV8sZTs. This particular commercial originated in Canada in 2003. See Viagra TV Ads from Canada, THE INSPIRATION ROOM (Nov. 12, 2005), http://theinspirationroom.com/daily/2005/viagra-tv-ads/.

(305.) See Plummer, supra note 51 (theorizing about such interactions of sex and culture); see also Franke, supra note 135, at 205 ("Men have almost entirely colonized the domain of sexuality that is the excess over reproduction as for them and about them.").

(306.) See Press Release, Boehringer-Ingelheim, supra note 3 ("'The need for a better understanding of HSDD [Hypoactive Sexual Desire Disorder] and its possible treatment continues, and we hope the scientific and medical communities will build on the knowledge that Boehringer Ingelheim's research has provided to find solutions for women who suffer with this disorder,' said Michael Sand, Director, Clinical Research and Global Strategic Leader of flibanserin, Boehringer Ingelheim.").

(307.) See ZOLA, supra note 189.

Susan Ekberg Stiritz, Ph.D.; M.S.W.: M.B.A.; Graduate Certificate, Women's Studies; Graduate, St. Louis Psychoanalytic Institute; Senior Lecturer, Women, Gender & Sexuality Studies, Washington University in St. Louis.

Susan Frelich Appleton, J.D.; Lemma Barkeloo & Phoebe Couzins Professor of Law, Washington University in St. Louis.

We both appreciate the thoughtful comments and other feedback from participants in the roundtable conference, "For Love or Money?," Washington University School of Law, March 25-27, 2010, and at the joint annual meeting of the International Society of Family Law (North American Region) and the Midwest Family Law Consortium, University of Missouri--Kansas City School of Law, June 3-5, 2010. We especially thank Marion Crain, Adrienne Davis, Rebecca Hollander-Blumoff, Thomas Maier, Linda Nicholson, Laura Rosenbury, and Marc Spindelman for their intellectual engagement in this project; Alexis Farris and Caitlin McGarr for research assistance; and Janice Houf for administrative support.
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